Director Plan Operations & Administration

Your career starts now. We are looking for the next generation of health care 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 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, 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 .Responsibilities:Act as a second in command to the Market President.Responsible for internal operational functions and oversight of corporate functions that support key plan requirements such as claims processing and encounter data submissions and corrections.Convene regular operational meetings at the plan to include peers, e.g., Provider Network Management, Compliance, Community Outreach, Provider Network Operations, Contract Management and IT Liaison to facilitate coordination of plan activities.Understand state program contractual and regulatory requirements (benefit and payment rules, data and information submission specifications, performance and service level requirements, etc.) and ensure requirements are met for the plan.Act as a liaison between the state, health plan and enterprise functions.Accountable for all contractual obligations and ensures that both local and corporate resources deliver on all commitments.Ensure that all service levels are met for all functional areas supporting the plan, including corporate, regional, and local functions. Addresses the need for corrective action when any service levels are not met.Oversee the submission of specific information to corporate, based on the plan's provider contracts, for configuration of the system to support payment of claims. Responsible for ensuring that claim payments, once configuration has been completed, are consistent with the terms of the contract.Maintain up-to-date Policies and Procedures for all local functions, conforming to regulatory requirements.;Track State Bulletins to identify changes and operational impacts, communicates them, and marshal local, regional and corporate resources to make necessary system and process changes to meet the requirements.Support the execution, in collaboration with the Regional CFO and CMO, of cost containment initiatives. Responsible for developing action plans and tracking results for operational cost containment initiatives.Proactively identify risks that would impact the Plan's ability to meet enterprise and local strategic and financial goals and develop strategies to mitigate the risks.Education/ Experience:Bachelor's Degree or equivalent combination of education and work experience required.Five to ten (5 to 10) years progressive manager/leader experience in a Managed Care Organization preferred.;Solid understanding of Medicare/Medicaid operations benefit administration required.Diversity, Equity, and InclusionAt AmeriHealth Caritas, everyone can feel valued, supported, and comfortable to be themselves. Our commitment to equity means that all associates have a fair opportunity to achieve their full potential. We put these principles into action every day by acting with integrity and respect. We stand together to speak out against injustice and to break down barriers to support a more inclusive and equitable workplace. Celebrating and embracing the diverse thoughts and perspectives that make up our workforce means our company is more vibrant, innovative, and better able to support the people and communities we serve.We keep our associates happy so they can focus on keeping our members healthy.Our Comprehensive Benefits PackageFlexible 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.;#HM

Created: 2025-04-05