Medicaid Provider Network Resolution Claims Analyst - Hybrid in DC

About the position At AmeriHealth Caritas, we're 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'd like to hear from 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. This position incorporates a hybrid work schedule working 1 day remotely and 4 days a week at our AmeriHealth DC office located 1201 Maine Avenue, S.W., Suite 1000, 10th Floor, Washington, DC 20024.

Responsibilities

• Responsible for configuration updates, resolution of claims inquiries, and all other system changes needed to facilitate timely and accurate payment of claims for par and non-par providers in our network.
• Ensure that each provider's status with the health plan is represented correctly in all plan operating systems.
• Support all projects with the Operations team and assist with resolution of provider issues.
• Responsible for data intake process including knowledge of relevant systems required to complete job functions.
• Conduct research and analysis related to contract updates, provider network or claim issues.
• Review assigned requests and ensure all requirements are met prior to processing.
• Document and track requests and monitor processing turnaround time.
• Effectively and professionally communicate to all parties concerned the pertinent information required to execute quality services.
• Escalate requests contrary to established business processes or contract language for resolution.
• Demonstrate a functional knowledge of provider data and managed care provider reimbursement methodologies.
• Support the investigation of claims issues, including troubleshooting, edit review, and submission for recycling/reprocessing as appropriate.
• Identify and report compliance issues in accordance with Plan policy and procedure.
• Demonstrate a functionally working knowledge of Facets, including the provider database and relay information about additions, deletions, or corrections to Provider Enrollment Services.
• Work with all departments to develop and execute strategies for optimally managing medical costs.
• Perform other duties and projects as assigned.
• Adhere to Plan policies and procedures.
• Attend required training sessions on an annual basis.

Requirements

• Bachelor's Degree or equivalent education with work experience required.
• One to two (1 - 2) years of Medicaid experience preferred.
• Three (3) years in the managed care/health insurance industry preferred.
• Proven experience with Excel spreadsheets: formulas, pivot tables, VLOOKUP's, etc.
• Knowledge/experience with Access Databases and working knowledge of at least one coding language (SQL, SAS, etc.).
• Previous claims experience strongly preferred.
• Previous provider relations experience preferred.
• Salesforce experience preferred.
• Facets experience preferred.
• Critical thinking/problem solving skills required.
• Must be interested in collaborating to solve complex problems within unknown systems, working with stakeholders at all levels.
• Must be team oriented and committed to organizational success.
• Must be willing and able to learn and adapt to new systems and processes.

Benefits

• 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.

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