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 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.

About this job:

Reporting to the SVP of Specialty Product Performance, the Senior Health Insurance Data Strategist (Data Strategist) drives data-informed decision-making to optimize performance across Specialty Products & Networks. The Data Strategist blends analytical expertise, technical proficiency in health insurance data, and strategic insight to support product growth, operational efficiency, and improved healthcare outcomes. The Data Strategist leverages data analytics, predictive modeling, and business intelligence to develop insights, influence decision-making, and foster innovation across the Specialty Products lines of business. Leveraging a strong background in Medicare and Medicaid and advanced technical expertise, this role translates complex data into actionable strategic insights for the enterprise and providers.

Responsibilities:

• Develop and execute data-driven strategies to improve financial performance, operational efficiencies, and healthcare quality across Specialty Products.

• To identify key strategic insights, utilize SQL and/or SAS to extract and analyze Medicare and Medicaid claims data, enrollment, risk adjustment, provider networks, and utilization trends.

• Identify and assess business opportunities and risks using predictive modeling, statistical analysis, and data visualization.

• Develop and document business rules, methodologies, and best practices for claims analysis.

Analytical Expertise:

• Work with large datasets, integrating multiple data sources (claims, financials, provider networks, social determinants of health, etc.) to identify patterns, trends, and opportunities for strategic process improvement.

• Apply advanced analytics techniques, including AI and statistical modeling, to advance key business initiatives.

• Conduct root cause analysis on claim denials, payment delays, and billing discrepancies. Ensure accurate processing and adjudication of claims while identifying errors, anomalies, and potential fraud.

• Develop and maintain dashboards and reporting tools using business intelligence (BI) tools (Tableau, Power BI, Looker, etc.) to support business decisions and for departmental and functional meetings.

• Provide ad-hoc reports and support to stakeholders as needed.

• Collaborate with IT and data engineering to ensure data integrity, governance, and compliance with HIPAA and other regulatory standards.

Business & Cross-Functional Collaboration:

• Partner with actuarial, finance, operations, clinical, and IT teams to align data strategies with business objectives. Collaborate with cross-functional teams, including Operations,

• Specialty Products, finance, compliance, and IT to optimize claims processing workflows.

• Drive collaborative initiatives to enhance risk stratification, population health management, and value-based care performance.

• Communicate complex data insights to stakeholders in a clear and actionable manner.

• Performance Optimization and Innovation

• Identify opportunities for automation, process improvement, and operational efficiencies.

• Stay ahead of industry trends, emerging technologies, and regulatory changes impacting health insurance and data analytics. Monitor and interpret CMS (Centers for Medicare &

• Medicaid Services) policies and regulatory updates to ensure compliance.

• Support system migrations, implementations, and upgrades related to claims processing.

Education & Qualifications:

• A bachelor’s degree in healthcare administration, computer science, data analytics, business, or another related field is required.;

• 8 to 10 years of experience in the healthcare/managed care industry.

• 7 plus years of experience in healthcare claims analysis, data analytics, or a data strategy-related role.

• Experience with healthcare claims adjudication systems (e.g., Facets, Amisys, QNXT, Epic, or similar).

• Strong knowledge of Tableau, Power BI, or other data visualization tools.

• Strong working knowledge and experience with healthcare predictive analytics, machine learning models, or risk adjustment methodologies.

• Proficiency in SQL (T-SQL, PL/SQL, or similar) and/or SAS for querying and analyzing claims data.

• Strong understanding of Medicare and Medicaid claims processing, billing codes (ICD-10, CPT, HCPCS), and reimbursement methodologies.

• Experience with healthcare payer systems, managed care organizations (MCOs), and provider networks.

• Knowledge of CMS regulations, HIPAA compliance, and healthcare data security.

• Proven experience in interpreting complex data sets and presenting insights to non-technical stakeholders.

• Experience with ETL processes, data validation, and data governance best practices.

• Strong problem-solving skills and attention to detail.

• Advanced analytical and quantitative skills with experience collecting, organizing, mining, analyzing, visualizing, and disseminating abundant information with the utmost accuracy and presentation.

• Prior experience in developing and implementing standards in a regulated environment.

• Ability to multi-task, manage time based on continually evaluating priorities, and meet deadlines with high-quality deliverables reflecting a complete understanding of expectations.

• Collaborate, influence, project confidence, identify organizational needs, and convincingly present statistical information, data analysis, and recommendations.

• Strong analytical, problem-solving, communication/presentation, and attention to detail skills.

• Understanding Value-Based Care (VBC), Accountable Care Organizations (ACOs), and Medicaid Expansion programs.

• Time management skills, with the ability to plan and execute projects on schedule.

Diversity, Equity, and Inclusion

At 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 Package

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 on Day 1, 401(k) tuition reimbursement, and more.

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As a company, we support internal diversity through:

Recruiting. We are an equal opportunity employer. We do not discriminate on the basis of age, race, ethnicity, gender, religion, sexual orientation, or disability. Our inclusive, equitable approach to recruiting and hiring reinforces our commitment to DEI.