AmeriHealth Caritas · 16 hours ago
Clinical Business Program Analyst
United States
Full-time
Remote
Entry Level
1+ years expAmeriHealth Caritas is a mission-driven organization delivering comprehensive healthcare solutions. The Clinical Business Program Analyst will manage Prior Authorization software applications, identify system enhancements, conduct testing, and oversee vendor relationships while ensuring compliance with Federal and State requirements.
Health CareInformation Technology
Responsibilities
Manage Prior Authorization (PA) and Coverage Determination (CD) software applications
Identify, document, and implement system enhancements and functionality updates based on Federal/State requirements, customer needs, and efficiency opportunities
Conduct system testing, validate results, and support production deployments
Identify, troubleshoot, and resolve application defects
Oversee application user account management
Manage outbound communications to members, prescribers, and pharmacies
Manage and audit vendor relationships involving:
Software development and coding
Pharmacy and medical claims processing
Electronic Prior Authorization (ePA)
Printing and mailing
Translation services
Automated phone call systems
Telephonic systems
Inbound/outbound fax services
Serve as Subject Matter Expert (SME) for Pharmacy Authorizations and their use in Pharmacy Claims Processing systems
Participate Fully In Audits, Including
Universe generation
Case file creation
Live audit participation
Monitoring industry and regulatory requirements
Gather, summarize, and present data using analytical tools; distribute information to Federal/State agencies, customers, and internal stakeholders
Develop staffing models for annual budgeting for Prior Authorization teams; produce productivity data for technician and pharmacist staffing levels
Design, run, and audit standard and ad hoc reports for:
Pharmacy and Medical Prior Authorization
Coverage Determinations and Redeterminations
Finance
Formulary Management
Clinical Outcomes and Optimization
Informatics
Specialty Pharmacy
Opioid Management
Hemophilia, Hepatitis C, High-Cost Medications
Manage projects including project plan development, tracking, and cross‑departmental collaboration. Oversee creation and maintenance of clinical criteria–based question sets used in PA/CD reviews (provider-facing and internal)
Create and update decision assessment protocols
Collaborate with clinical staff (pharmacists, technicians)
Research industry trends and data
Audit protocol effectiveness and usage
Manage departmental SharePoint reference and help sites, ensuring functionality, accuracy, and user accessibility
Track and report operational productivity improvements within Clinical Services
Build and maintain Access databases; perform queries, reporting, and data mining
Prepare validated datasets using Excel and other tools
Support departmental and interdepartmental goals; maintain positive working relationships
Attend required annual training
Maintain confidentiality of all information; uphold professional appearance and conduct
Perform other duties and projects as assigned
Qualification
Required
High School Diploma/GED required
Current Pharmacy Technician Certification (PTCB or ExCPT), or ability to obtain within 12 months of hire
1–3 years of relevant experience
Recent experience in application management, including: Enhancement requirement writing, Regression testing, Debugging, Production deployment support
Proficiency with Microsoft Office Suite, including: Excel, Access, Project, Visio
Experience with Tableau for reporting and data analysis
Preferred
Bachelor's Degree preferred
Benefits
Flexible work solutions include remote options, hybrid work schedules
Competitive pay
Paid time off
Holidays and volunteer events
Health insurance coverage for you and your dependents starting Day 1
401(k) retirement savings plan
Tuition reimbursement
And more.
Company
AmeriHealth Caritas
AmeriHealth Caritas is the health care solutions provider for those in most need and the chronically ill.
10001+ employees
Funding
Current Stage
Late StageLeadership Team
Kathleen Giblin
SVP Clinical Operations
Ash Hanson
Executive Vice President & Chief Human Resources Officer
Recent News
2025-11-06
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2025-10-02
2025-10-01
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