Qureos Mentor

AmeriHealth Caritas

<div>Role Overview: The Provider Network Operations Data Analyst plays a key role in maintaining accurate provider data and fostering strong relationships between the health plan and its contracted and non-contracted providers across Medicaid, Medicare, and Exchange products. This role ensures provider information is correctly represented in all operating systems and serves as a proactive liaison to resolve provider-related issues efficiently.
Work Arrangement:<ul><li>
Remote &ndash; The associate can work remotely from anywhere in the Detroit Metro area, Michigan, and must be able to attend two weeks of in-office training at our Southfield, Michigan, location.</li></ul>
Responsibilities:<ul><li>
Serve as a primary point of contact for providers, ensuring timely resolution of inquiries and issues.</li><li>
Communicate plan policies, procedures, and regulatory updates clearly and professionally.</li><li>
Maintain and monitor provider data to ensure accuracy across all systems.</li><li>
Review and process provider data intake forms for completeness.</li><li>
Track and document provider data changes to ensure timely updates and compliance with turnaround standards.</li><li>
Escalate discrepancies or requests that conflict with business processes or contract terms.</li><li>
Ensure timely and accurate management of provider contracts, including terms and reimbursement details.</li><li>
Investigate and respond to member complaints within established timelines.</li><li>
Identify and report compliance issues in accordance with plan policies and procedures.</li><li>
Demonstrate working knowledge of provider databases (e.g., Facets) and reimbursement methodologies.</li><li>
Collaborate with internal departments to manage medical costs and support strategic initiatives.</li><li>
Demonstrates working knowledge of Facets, particularly the provider database, and consistently communicates updates, such as additions, deletions, or corrections, to the provider maintenance department.</li></ul>
Education &amp; Experience:<ul><li>
Bachelor&rsquo;s degree or equivalent work experience required.</li><li>
At least one year of experience working with healthcare providers and provider relations</li><li>
3 years of experience in managed care or health insurance preferred.</li><li>
Proficiency in Microsoft Excel &amp; Access (formulas, pivot tables, charts/graphs).</li><li>
Strong analytical skills (non-IT focused)</li></ul></div>

Provider Network Operations Data Analyst

<div>Role Overview
In this role, you will provide daily operational leadership to a team of 13 remote Utilization Management Technicians. This team supports the intake of physical health utilization management reviews specific to First Choice by Select Health of South Carolina. As one of 6 Supervisors, Utilization Management Review Non Clinical, you will ensure all processes are completed and deadlines are met and in compliance with local, state, and federal regulatory standards.
<ul><li>Provides technical assistance and coaching to staff in a prompt and ongoing basis to ensure accuracy and completion of work according to regulatory guidelines, AmeriHealth Caritas policies, procedures, and process standards.</li><li>
Identifies the need for and develops policies and procedures, and training and education plans to assure that Care Connector or other pertinent staff process standards are clearly documented, and meet/support organizational goals.</li><li>
Maintains a current knowledge base of Intake or other appropriate staff processes and trains/ mentors staff.</li><li>
Works collaboratively with Utilization Management Supervisors, Managers and Directors to identify and resolve workflow issues and obstacles to efficient departmental and individual performance.</li><li>
Maintains current knowledge of all Utilization Management initiatives, attends assigned meetings and actively communicates with departmental representatives Intake staff or pertinent staff work duties and participates in the development of Policies &amp; Procedures, Standard Operating Processes, Training development and presentations to direct reports and other departments</li><li>
May utilize work force management systems, as dictated by leadership, to effectively monitor the processing of inbound calls/ contacts. Responsible for preparing reports and conducting analysis of UM Technicians or pertinent staff productivity and attainment of goals. Performs other related duties and projects as assigned.</li></ul>
Education/Experience:<ul><li>
High School Diploma or GED required; Associate's Degree preferred</li><li>
Minimum of 3 years experience supervising staff in a contact center environment with processes to provide accountability in high volume call environment, preferred working in a health care/managed care environment.</li><li>
Strong knowledge base of health care resources, ideally with managed care experience.</li><li>
Excellent communication skills, oral written; excellent listening skills.</li><li>
Solid knowledge of contact center processes to provide accountability in high volume call environment, managing audits/reports.</li><li>
Demonstrated ability to promote excellent customer service skills.</li><li>
Skill in working with diverse teams and ability to collaborate with various disciplines within a market or Plan is highly desirable.</li></ul>
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.</div>

Non Clinical Intake UM Review Supervisor

<div>PerformRx is a Pharmacy Benefits Manager (PBM) dedicated to clinical culture, boutique service, and holistic solutions. Our mission is to help clients, providers, and members use effective medication therapy to improve health and wellness. For over two decades, our focus has been on providing optimal service through a clinical culture that seeks to provide members with high-quality care while ensuring our partners receive favorable costs. That culture is reflected in our employees &mdash; more than 80 percent of our staff members are Pharmacists and Pharmacy Technicians &mdash; and in the services we provide.
PerformRxis headquartered in Philadelphia. Our dedication to innovation and to providing the most efficacious outcomes is the core of our clinical culture and is the heart of PerformRx. PerformRx is a subsidiary of the AmeriHealth Caritas Family of Companies.
Role Overview
The Pharmacy Technician I supports the organization&rsquo;s mission and purpose by providing front-line customer support for a diverse portfolio of customers. The incumbent willhandle inbound telephone inquiries from Members, pharmacies, and Prescribers in our National Customer Care Center, and will consistently meet established productivity, schedule adherence, and quality standards.
Work Arrangement<ul><li>
Remote</li></ul>
Responsibilities<ul><li>
Provide real-time support to pharmacies with point-of-service inquiries</li><li>
Educate prescribers on formulary and prior authorization processes</li><li>
Enter customer data and other relevant information into our documentation tool</li><li>
Assist members with pharmacy benefit inquiries</li><li>
Adhere to standard operating procedures to ensure contact handling accuracy and operational effectiveness</li><li>
Effectively communicate issues and resolutions to customers and appropriate internal staff</li></ul>
Education and Experience<ul><li>
Bachelor's degree or equivalent experiencerequired</li><li>
Minimumthree (3) yearsof current/recent PBM and/or current/recent pharmacy experiencerequired</li></ul>
Licensure<ul><li>
Active/current National Pharmacy Technician Certification (NHA or PTCB) or ability to obtain one within the first six (6) months of employment isrequired</li></ul>
Your career starts now. We are looking for the next generation of healthcare 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 healthcare 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
Our Comprehensive Benefits Package
Flexible work solutions include remote options, competitive pay, Paid Time Off (PTO), including holidays and volunteer events, health insurance coverage for you and your dependents on Day 1, 401(k), tuition reimbursement, and more.</div>

Pharmacy Technician I

Join AmeriHealth Caritas and explore 3   exciting career opportunities. They're hiring for various roles with options for remote or on-site work. Apply today and become part of their innovative team.

AmeriHealth Caritas

About Company

Provider Network Operations Data Analyst

Non Clinical Intake UM Review Supervisor

Pharmacy Technician I