Data Analyst

Role Overview

The Prior Authorization Data Analyst leads governance of prior authorization processes across the enterprise through data-driven insights, workflow analysis, and trend identification. This role drives strategic authorization practices to optimize value, improve compliance, and reduce waste.

You’ll analyze claims, reimbursement policies, and payment practices to identify opportunities and ensure compliance with state contracts and CMS regulations, while serving as the subject matter expert for enterprise-wide prior authorization rules.

Key Responsibilities

• Govern and maintain the enterprise-wide prior authorization list across all lines of business.

• Identify discrepancies between benefit category structures and authorization rules; recommend corrective action.

• Extract, manipulate, and analyze large datasets using SQL and data mining tools.

• Submit and track updates via Appian for prior authorization rules and lookup tools.

• Facilitate the Prior Authorization Review Committee (PARC) meetings:

  • Serve as gatekeeper for rule change requests.

  • Present requests and updates (CMS code updates, annual rule reports, ad-hoc changes).

  • Communicate PARC decisions to stakeholders.

  • Generate work requests and collaborate with configuration/plan operations.

• Develop standardized reporting of authorization and claims data for review by PARC.

• Communicate changes in authorization requirements to impacted departments (population health, operations, configuration, etc.).

• Assist in building rules and benefit structures for new lines of business and implementations.

• Act as the enterprise-wide subject matter expert on prior authorization governance.

Education & Experience

• Associate’s degree required; Bachelor’s degree preferred.

• CPC Certification preferred.

• 5+ years in prior authorization, utilization management, or managed care, with SQL/data mining experience.

• Strong proficiency in SQL; experience with SAS a plus.

• Familiarity with evidence-based clinical decision support tools (e.g., InterQual) preferred.

• Knowledge of claims and authorization systems (Facets, JIVA preferred).

• Excellent communication, critical thinking, and organizational skills.

• Proficiency with MS Office (Word, Excel, Outlook) and Windows 11 applications.

About AmeriHealth Caritas

At AmeriHealth Caritas, we help people get care, stay well, and build healthier communities. With over 30 years of experience, we are a mission-driven leader in healthcare solutions, offering managed care, pharmacy services, behavioral health, and more.

🌐 Learn more: amerihealthcaritas.com

Benefits

• Flexible work options (remote/hybrid).

• Competitive pay with Day 1 health insurance coverage (for you & dependents).

• Paid time off, including holidays & volunteer days.

• 401(k) with company match.

• Tuition reimbursement & professional development support.