Job Description

JOB DESCRIPTION:

Your career starts now. We’re looking for the next generation of healthcare leaders.

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 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’d like to hear from you.

Headquartered in Philadelphia, 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.

RESPONSIBILITIES:

Under the general direction of the Operations Call Center Supervisor, responsible for:

• Responding in a timely, professional and courteous manner to all customer needs. This includes provider phone calls or correspondence regarding benefits, eligibility, and other provider issues.
• Reviews and adjudicates claims based on provider and health plan contractual agreements and claims processing guidelines.
• Serves as a Subject Matter Expert.
• Conducts cross-training to staff as required.
• Demonstrates solid knowledge of Provider Service/Claim systems, functions and team processes.
• Demonstrates superior skill in dealing with provider issues/inquiries, team members, and co-workers.
• Suspends claims requiring additional information and/or special handling; initiates action to obtain required information.
• Forwards claims requiring external department intervention to the appropriate department or person.
• Monitors outstanding inquiries and works with management staff to identify and resolve areas of non-compliance.
• Reviews and verifies quality audit reports.
• Reconciles audit discrepancies, corrects in system and makes appropriate changes to avoid recurrence.
• Maintains thorough knowledge of claims process systems, its databases and subsystems.
• Responds to and resolves provider and health plan claim inquiries. Monitors and tracks aged, pended, and open reports to maintain timeliness in claims processing.Inputs claims into the system for appropriate tracking and processing.
• Documents file, as appropriate, to support payment decision.
• Serves as a Subject Matter Expert and conducts training as required.
• Conducts cross-training to staff as required.
• Actively participates in user acceptance testing functions, such as test script development, testing and documentation of test results.

EDUCATION/EXPERIENCE:

• Minimum 4 years’ experience in claims and/or call center required.
• High School/GED required.
• Associate degree preferred; minimum 45 wpm typing preferred.
• Healthcare or Managed Care experience preferred.
• Working knowledge of PC apps in a windows based environment.

Company Description

Welcome to AmeriHealth Caritas, the new name in health care solutions for the underserved—formerly The AmeriHealth Mercy Family of Companies. Our corporate name has changed but our mission has not. We’re still the same company, dedicated to helping people get care, stay well, and build healthy communities. AmeriHealth is synonymous with innovative, cost-effective managed care solutions for publicly funded-programs. For three decades we’ve been a leading provider of health care for those who need it most. A higher level of care is what sets us apart. From our award-winning clinical services to our innovative outreach programs, we’re making a real difference in the lives of our members. What makes us different is as personal and unique as a signature: Care is the heart of our work.