Operations Quality Auditing Analyst

For roles that are 100% remote or hybrid, you must have access to a reliable high-speed internet connection to support daily job responsibilities. A minimum bandwidth of 50 Mbps download and 5 Mbps upload is required. Those fully remote associates residing in states where service is required by contract, law, or regulation will be allowed to submit for reimbursement.


Your career starts now. We are looking for the next generation of health care leaders.


At AmeriHealth Caritas, we are passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we would like to connect with you.


Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.


Discover more about us at www.amerihealthcaritas.com.


Role Overview:


The primary purpose of the Operations Quality Auditing Analyst is to provide high-level technical expertise and analysis to the functional areas supported by the Quality Auditing department. They will work closely with configuration, PDM, and Plans to identify the root cause and drive to resolution.


Work Arrangement: Hybrid= Associate must be in the office at least three (3) days per week, including core days of Tuesdays and Wednesdays


Responsibilities:


+ Function as a key subject matter expert for all claim research and analysis

+ Be proficient in claim payment methodology for all plans

+ Have experience in researching State and CMS guidelines – including APR DRG and OPPS methodology

+ Maintain a current working knowledge of processing rules, contractual guidelines, Plan policy, and operational procedures to effectively provide technical expertise

+ Support the new business claim validation efforts by reviewing claim setup and identifying issues for quick remediation

+ Proficient in Contract Manager and all contract/PAT forms

+ Assist in analysis on pre-adjudication, target audits, and encounter reviews as required

+ Ability to research claim-related encounter errors and ascertain the root cause

+ Ability to communicate and represent the Quality Auditing team to the Enterprise, health plans, and outside auditors

+ Utilize various technology applications related to claim processing, provider data management, enrollment, etc. (Excel/Access/Word)

+ Identify audit trends and provide recommendations

+ Train the new QA staff on the pricing methodology for all plans.


Education/Experience:


+ Bachelor’s Degree or equivalent work experience

+ Minimum of 3 years of extensive claims experience


Skills & Abilities:


+ Strong understanding of facets applications

+ Critical thinking skills

+ Technically proficient

+ Proficient in MS Excel and Word


Our Comprehensive Benefits Package


Flexible work solutions including remote options, hybrid work schedules, Competitive pay, Paid time off including holidays and volunteer events, Health insurance coverage for you and your dependents on Day 1, 401(k) Tuition reimbursement and more.
As a company, we support internal diversity through:

Recruiting. We are an equal opportunity employer. We do not discriminate on the basis of age, race, ethnicity, gender, religion, sexual orientation, or disability. Our inclusive, equitable approach to recruiting and hiring reinforces our commitment to DEI.