; **Job Summary** The Prior Auth Data Analyst is responsible for governing the Prior Authorization processes and procedures across the Enterprise through data driven insights, workflow analysis and trend identification. The Prior Auth Data Analyst helps establish strategic authorization practices that will optimize value for the company. Responsible for requesting and analyzing claims reports, reimbursement policies and payment practices to identify trends, maximize internal resources and minimize waste. The Prior Auth Data Analyst makes recommendations for authorization requirements in accordance with state contracts and CMS regulations.; **Responsibilities:** + Adheres to workflows, Standard Operating Procedures, and Policies and Procedures, as defined by leadership team. + Analyzes utilization patterns to determine value-based opportunities for the company. + Recognizes opportunities for HVO initiatives and brings to leadership. + Provides support and oversight to the corporate prior authorization process which includes providing expertise and direction for all enterprise-wide prior authorization rules + Maintains the enterprise-wide prior authorization list to include each line of business’ prior authorization rules and benefit category structure. + Identifies and eliminates discrepancies between prior authorization and benefit category structure rules between lines of business + Utilizes SQL to extract manipulate and analyze large datasets. + Submits and tracks work requests through Appian to update the prior authorization list and Prior Auth Lookup Tools as needed + Facilitates the Prior Auth Committee meeting to support enterprise-wide prior authorization standardization taking into consideration regulatory or contractual exceptions.; + Facilitation also includes: + being the gatekeeper for any request to change prior authorization rules + ;presenting these requests to PARC + communicating PARC decisions back to applicable stakeholders + ensure meeting agendas and meeting minutes are updated and distributed appropriately + generate all applicable Appian work requests + collaborate with configuration/plan ops as needed + complete and present to committee: + CMS Code updates + Annual prior authorization rule reports (claims and utilization) + Ad-hoc prior authorization rule change request + Responsible to develop and ensure maintenance of standardized reporting of all authorization and claims data for each line of business which will be presented to PARC for analysis and to make informed decisions for authorization requirements.; + Responsible to ensure any changes in prior authorizations are communicated accurately and timely to all impacted departments (ie: population health, operations, configuration, prior authorization code look up, etc.). + Routinely reviews the prior authorization list and ensures accuracy with the configuration benefit grid.; + Assists in developing prior authorization rules and benefit category structure for new lines of business. + Lead or participate in discussions surrounding auth requirements for any new business implementations. + Enterprise-wide subject matter expert for the prior authorization list and governance. ; **Education/Experience:** + Associate’s Degree required. Bachelor's Degree preferred. + Certified Professional Coder (CPC) Certification preferred. + Strong proficiency in SQL, data mining (SAS). + Minimum of 5 years of experience in prior authorization, utilization management in a managed care organization, SQL or data mining. + Experience utilizing evidence based clinical decision support tools, such as InterQual, desired. + Excellent communication, analytical, and critical thinking skills. Detail oriented and strong organizational skills. + Demonstrated ability to prioritize and multi-task to ensure deadlines for deliverables are met. + Working knowledge of MS Office including Word, Excel, and Outlook, and Internet applications in Windows 11. + Proficiency utilizing claims and authorization management systems. Facets and JIVA would be preferred. ; Your career starts now. We’re looking for the next generation of health care 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 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’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 . **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. ; 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.