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AmeriHealth Caritas · 7 hours ago

Manager Provider Network Operations

United States

Full-time

Remote

Mid Level

3+ years exp

AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience in delivering comprehensive healthcare solutions. The Manager Provider Network Operations is responsible for overseeing provider data and reimbursement rules, managing the Provider Reimbursement department, and ensuring compliance with state policies.

Health CareInformation Technology

H1B Sponsor Likely

Responsibilities

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

Serves as the subject matter expert in State specific health reimbursement rules and provider billing requirements and as liaison to the Enterprise Operations Configuration Department

Manages the day-to-day activities of the Provider Reimbursement department and staff

Supervises, directs, monitors, reviews and coaches all Provider Reimbursement staff members and their work performance

Assists with activities related to provider satisfaction, communication, and compliance

Responsible for the analysis of provider reimbursement and updating codes and fee schedules for correct reimbursement to providers

Develops the Pricing Agreement Templates (PAT) for all provider reimbursement set up and updates

Ensures all configuration documentation is completed timely and accurately, in accordance with State and provider contract requirements

Represent the Plan in provider meetings, including training and joint operating committee, as well as internal and external audits

Review and respond to operational inquiries from state partners and/or other regulating bodies

Participate in Provider Reimbursement medical policy and edit reviews

Ensures ongoing provider data accuracy through regular reconciliation of the state provider master file, provider rosters, and audits

Oversees process of root cause analysis for claims payment issues related to provider reimbursement and provider set up

Maintain/oversee tracking system of operational issues, progress, and status

Oversee Plan related encounter activities as assigned by the Enterprise Encounter Team

Oversee validation of potential recovery claim project activities

Performs other related duties and projects as assigned

Qualification

State Medicaid requirementsHealthcare claims processingProvider reimbursement rulesMedical billing principlesCustomer ExcellencePersonal management skillsCoordination across functionsCommunication

Required

Three to five years in a health care or related state policy Experienced in State specific Medicaid requirements

Understanding of and experience related to healthcare claims payment configuration process/systems and its relevance/impact on network operations required

Excellent written and verbal communication

Track record of Customer Excellence

Bachelor's Degree or equivalent experience/education

Demonstrated ability to coordinate activities across functional areas

Sound personal management skills to plan, organize, schedule, and complete own work and work that is coordinated with others

Knowledge of the delivery of health care services and medical billing principles

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

And more.

Company

AmeriHealth Caritas

Glassdoor3.4

AmeriHealth Caritas is the health care solutions provider for those in most need and the chronically ill.

Founded in 1982

Philadelphia, Pennsylvania, USA

10001+ employees

http://www.amerihealthcaritas.com

H1B Sponsorship

AmeriHealth Caritas has a track record of offering H1B sponsorships. Please note that this does not guarantee sponsorship for this specific role. Below presents additional info for your reference. (Data Powered by US Department of Labor)

Distribution of Different Job Fields Receiving Sponsorship

Represents job field similar to this job

Trends of Total Sponsorships

2025 (18)

2024 (17)

2023 (12)

2022 (14)

2021 (4)

2020 (11)