Philadelphia, PA, USA
icrunchdata Network
JOB BRIEF Continuously review/refine processes and plans for improvements by collecting and interpreting data Min 1 yr of PBM, Medicare, Medicaid, and/or compliance experience required Your career starts now. Were looking for the next generation of health care leaders. At AmeriHealth Caritas, were 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, wed 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 [ SUMMARY: To ensure continuous improvement of processes; continuously reviews and refines processes and plans for improvements by collecting and interpreting data and by developing recommendations and presenting summary findings to department leadership. RESPONSIBILITIES: Understand CMS guidance related to PDE processing and reporting Analyze and interpret encounter data to identify potential issues and trends Monitor, manage, and audit monthly data submission ensuring timely and accurate submissions Coordinate efforts to perform corrections and report on encounter data rejects within guidelines Set-up, coordinate, and troubleshoot all pharmacy data files including eligibility Work with the downstream processes from adjudication (i.e., PDEs, Encounters, and all State required data files) Engage as a Subject-Matter Expert (SME) on pharmacy data particularly PDE, Encounter, and Eligibility data Ensure the data integrity of various pharmacy data sources including claims, PDE Acumen, and other vendor data is maintained throughout the process of importing and storing Prepare analysis on PDE errors and out of balance records, validates claim adjudication to plan design and PDE Ensure all work is completed within timeline allowed by CMS Business Partner to corporate IS for new initiatives, trouble shooting file transfers, and project related tasks Responsible for the overall management of all PerformRx Web based and E-Business offerings including but not limited to Web Site design and maintenance, Member, Provider and Client Portals, Electronic transactions with internal and external vendors and Intranet sites Perform other related duties and projects as assigned by the department Director or Regional Supervisor Support and carry out the PerformRx Mission & Values Adhere to all AmeriHealth Caritas and PerformRx policies and procedures Maintain a current knowledge base of PerformRx programs, services, policy and procedures Regularly review and adhere to standard operating guidelines, desktop procedures, checklists, templates, and memorandums issued to the department Create and support an environment which fosters teamwork, cooperation, respect and diversity. Establish and maintain positive communication and professional demeanor with PerformRx employees and customers at all times Demonstrate and support commitment to corporate goals and objectives EDUCATION/ EXPERIENCE: High School Diploma or equivalent required; Bachelors degree preferred Active/current National Pharmacy Technician Certification (ExCPT, NCCT, PTCB) preferred Minimum one (1) year ofPharmacy Benefit Manager (PBM), Medicare, Medicaid, and/or compliance experience required Progressive and focused work experience in continuous improvement initiatives, project management, and/or organizational development required Problem solving ability and experience with managing multiple assignments with critical deadlines required Claims knowledge or experience is a plus Minimum three (3) yearsof SAS, SQL, or comparable programming language is preferred Back [ Share Apply Now [