NewProvider Enrollment Specialist AmeriHealth CaritasProvider Enrollment SpecialistNewtown Square, PAThe Provider Enrollment Specialist, under the direct supervision of the Provider Enrollment Supervisor, is responsible for maintaining participating and non‑participating provider records in the provider database, mapping claims in the invalid provider queue, and resolving provider‑related issues for claims suspended to Provider Enrollment. Our services include integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.
Provider Network Management Specialist AmeriHealth CaritasProvider Network Management SpecialistWashington, DCRemote$71,600–$97,500 / yearThe primary responsibility of Account Executive is to develop strong relationships with providers to drive for performance, specifically as it relates to core providers as determined by the program who are in fee for service programs and may include PCPs, OB/GYNs, high volume specialists, and FQHCs. + Maintains in depth understanding of Plan’s contracts and provider performance and needs, identifying, and conducting relevant and tailored provider orientation sessions, making educational visits and working to resolve provider issues.
Director Strategy & Planning AmeriHealth CaritasDirector Strategy & PlanningNewtown Square, PALead a team in the day-to-day execution of assigned initiatives and projects including developing work plans, tracking progress against objectives, identifying metrics of success, collaborating with stakeholders, and leading purpose-driven meetings with business leaders. + Facilitate strategic growth discussions among business leaders to drive the identification and prioritization of growth opportunities and strategies, and drive the development of an enterprise growth strategy and cohesive enterprise growth plan, including an annual assessment of the corporate asset portfolio (Medicaid, Medicare, Exchange, Pharmacy, Behavioral Health).
Digital QA and Testing Analyst AmeriHealth CaritasDigital QA and Testing AnalystNewtown Square, PARemoteExecute manual QA testing across assigned websites, portals, and digital releases; validate requirements, user flows, forms, links, navigation, and functional performance; document test results and escalate release-blocking defects or quality risks as needed. This professional-level role applies working knowledge of digital accessibility guidelines, assistive technologies, and testing tools to identify defects, document findings, support remediation, and validate fixes across digital platforms.
Care Manager II AmeriHealth CaritasCare Manager IIDover, DERemoteMeets regularly with designated partners regarding plan-identified members for care management, assists with reducing/resolving problems and or barriers so that the ACDE Care Coordinator may provide members with high-quality care management services. + Completes comprehensive person-centered assessment, inclusive of physical health history, mental health history, social determinants of health, and supportive needsCoordinates physical, behavioral health, and social services.
Service Coordinator-CHC AmeriHealth CaritasService Coordinator-CHCPhiladelphia, PARemote3+ years of social service (in lieu of a Bachelor’s degree) or related healthcare experience that required the following: + working with people who need personal care services, + conducting face to face visits in the home or nursing facility focused on needs assessments and monitoring delivery of services. You will contribute to the care coordination process by performing face-to-face assessments to identify, evaluate, coordinate, and manage participant's needs, including physical health, behavioral health, social services, and long-term services and support, as well as telephonic follow-up.
Appeals & Grievance Case Resolution Specialist AmeriHealth CaritasAppeals & Grievance Case Resolution SpecialistPhiladelphia, PARemoteThe Specialist serves as a key liaison between members, providers, and internal departments to resolve issues effectively, ensuring the integrity of the appeals and grievance process and compliance with CMS, NCQA, URAC, and state regulatory requirements. + Communicate with members, providers, or representative to clarify appeal intent and gather missing documentation including incoming calls, outgoing calls, and phone queue work as assigned.
Care Manager AmeriHealth CaritasCare ManagerMillsboro, DERemoteMeets regularly with designated partners regarding plan-identified members for care management, assists with reducing/resolving problems and or barriers so that the ACDE Care Coordinator may provide members with high-quality care management services. + Completes comprehensive person-centered assessment, inclusive of physical health history, mental health history, social determinants of health, and supportive needsCoordinates physical, behavioral health, and social services.
NewPharmacist AmeriHealth CaritasPharmacistRaleigh, NCRemoteAs a licensed healthcare professional employed in the Prior Authorization Department, the primary responsibility of the Pharmacist (R) is to make determinations on prior authorization requests for coverage of pharmaceutical products. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.
Maternal Care Manager AmeriHealth CaritasMaternal Care ManagerDover, DERemoteMeets regularly with designated partners regarding plan-identified members for care management, assists with reducing/resolving problems and or barriers so that the ACDE Care Coordinator may provide members with high-quality care management services. + Completes comprehensive person-centered assessment, inclusive of physical health history, mental health history, social determinants of health, and supportive needsCoordinates physical, behavioral health, and social services.
Supervisor, Claims Provider Network Operations (PNO) AmeriHealth CaritasSupervisor, Claims Provider Network Operations (PNO)Southfield, MIRemoteRole Overview: The Provider Network Operations Supervisor supports the daily operations of the Provider Network Operations team by overseeing staff performance, ensuring operational efficiency, and maintaining compliance with internal policies and contractual requirements. + Ensure operational processes align with internal policies, contractual obligations, and service level agreements (SLAs).
NewMedical Director Utilization Management AmeriHealth CaritasMedical Director Utilization ManagementIndianapolis, INRemoteAs 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. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.
Maternity Case Manager AmeriHealth CaritasMaternity Case ManagerCharlotte, NCRemoteCoordinates physical, behavioral health and social services; + Provides medication management, including regular medication reconciliation and support of medication adherence; + Identifies problems/barriers for care coordination and appropriate care management interventions. The Maternity Care Manager provides support to pregnant members appropriate for care coordination and case management services in achieving their optimal level of health through self-management.
Customer Service Representative AmeriHealth CaritasCustomer Service RepresentativeJacksonville, FLUnder the direct supervision of Operation Supervisors, the Customer Service Representative is responsible for supporting a diverse membership community and their providers as well as other customers in a timely manner. Our services include integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.
Director Long Term Services & Support AmeriHealth CaritasDirector Long Term Services & SupportCharleston, SCRemoteServe as primary LTSS subject matter expert and leader responsible for coordinating, overseeing, directing all health plan LTSS operations, inclusive of internal and external communications, regulatory requirements, network development, systems integration, and clinical programs. + Support coordination of LTSS with other services across the continuum of care striving to enhance the quality of member care and provider satisfaction, including participation on multidisciplinary care teams as indicated.
Data Management Business Systems Analyst Senior AmeriHealth CaritasData Management Business Systems Analyst SeniorNewtown Square, PARemoteIn accordance with established regular communications with Manager, keeps staff apprised of progress, problems, and objectives, and initiatives discussions and solicits input regarding business priorities, plans, and progress. + Assists in managing large scale projects, leads appropriate resources and determines project requirements and deliverables, to ensure successful implementations to meet ACFC user needs.
NewProvider Claims Service Representative AmeriHealth CaritasProvider Claims Service RepresentativePhiladelphia, PAActively participates in user acceptance testing functions, such as test script development, testing and documentation of test results. Under the general direction of the Operations Call Center Supervisor, responsible for responding in a timely, professional and courteous manner to all customer needs.
Customer Service Representative AmeriHealth CaritasCustomer Service RepresentativePhiladelphia, PAUnder the direct supervision of Operation Supervisors, the Customer Service Representative is responsible for supporting a diverse membership community and their providers as well as other customers in a timely manner. Our services include integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.
Behavioral Health Utilization Management Reviewer AmeriHealth CaritasBehavioral Health Utilization Management ReviewerWashington, DCRemote$77,700–$105,900 / yearUsing clinical knowledge and experience, the clinician reviews provider requests for inpatient and outpatient services, working closely with members and providers to collect all information necessary to perform a thorough medical necessity review. The BH UM Reviewer will use professional judgment to evaluate the request to ensure that appropriate services are approved and recognize care coordination opportunities and refer those cases to integrated care management as needed.
Utilization Management Reviewer AmeriHealth CaritasUtilization Management ReviewerWashington, DCRemote$86,000–$117,300 / hourMinimum of 3 years of diverse independent clinical practice experience as a Registered Nurse in outpatient surgery, Medical-Surgical, Critical Care, Skilled Nursing Facility (SNF), Rehabilitation, or Long-Term Acute Care (LTAC) settings. Under the direction of a supervisor, the Utilization Management Reviewer evaluates medical necessity for inpatient and outpatient services, ensuring treatment aligns with clinical guidelines, regulatory requirements, and patient needs.