http://www.amerigroup-jobs.com/feeds/Investigator-Dallas-Fort-Worth-TX-jobs/ Custom RSS Feed for Investigator-Dallas-Fort-Worth-TX-jobs Tue, 21 May 2013 21:32:32 GMT en-us /sites/amerigroup/images/banner.gif http://www.amerigroup-jobs.com/feeds/Investigator-Dallas-Fort-Worth-TX-jobs/ 720
Job ID 2013-22805 # Positions 1
Location US-TX-San Antonio
Search Category Customer Service
Type Regular Full-Time (30+ hours) Posted Date 5/14/2013
Additional Locations ..

More information about this job:
Summary:

The incumbent is responsible coordinating the resolution of claims issues by actively researching and analyzing systems and processes that span across multiple operational areas.

This position may be located in San Antonio, Lubbock, El Paso, Houston, or the Dallas/Fort Worth area.

Responsibilities:

1. Investigates and facilitates the resolution of claims issues, including incorrectly paid claims, by working with multiple operational areas and health plans and analyzing the systems and processes involved in member enrollment, provider information management, benefits configuration and/or claims processing.

2. Identifies the interdependencies of the resolution of claims errors on other activities within operations.

3. Assists in the reviews of state or federal complaints related to claims. Coordinates the efforts of several internal departments to determine appropriate resolution of issues within strict timelines.

4. Interacts with network providers and health plans regularly to manage customer expectations, communicate risks and status updates, and ensure issues are fully resolved.

5. Performs claims and trend analysis, ensures supporting documentation is accurate and obtains necessary approvals to close out claims issues.

6. Recommends new or modified processes and procedures to reduce claims errors, taking into consideration business requirements and system limitations.

7. Performs user acceptance testing to ensure new contracts are loaded correctly and system modifications are accurate.

8. Performs other duties as assigned.

Qualifications:

EDUCATION AND EXPERIENCE

Education

Required:
- Bachelor’s degree, or equivalent related experience

Years and Type of Experience Required:

Required:
- Five years of claims research and/or issue resolution or analysis of reimbursement methodologies within the health care industry

Language Skills

Required:
- English

Technical Competencies

Computer Skills and Office Equipment
- Ability to use software and hardware of a computer to complete certain moderately-complex to complex tasks.
- Able to use basic office equipment such as telephone, fax machine and copy machine.
- Working knowledge in a windows environment to include navigation skills using a mouse, keyboard and 10 key.
- Use of internet, familiarity with SharePoint sites.
- Ability to review and draft correspondence in email system and word processing systems.
- Ability to use software for data analysis, reporting and sharing of information to problem solve.
- Ability to create and manipulate spreadsheets (i.e., data entry and format cells).
- Ability to work in databases.

Office Math Skills
- Ability to process numbers, which is an essential skill for any problem solving situation in a claims environment.
- Skills in the use of a calculator (using percentages, multiplication and division) to determine appropriate benefit payment.
- Ability to calculate the manual pricing of claims.
- Skills to verify accuracy with visual percentage calculations.

Read, Interpret and Apply Information
- Ability to research information using available resources.
- Read and comprehend the information to analyze and apply logical thinking in making sound decisions.
- Understand and apply general instructions to appropriately and accurately process claims.
- Capacity to follow step-by-step and general directions, remain detail oriented and verify data including HIPAA documentation.
- Ability to investigate and review claim from initial receipt.
- Ability to apply in-depth problem solving with more complex claims.
- Ability to read and interpret contracts for outpatient and inpatient claims.
- Ability to prepare written communication to providers documenting the results of their inquiry.
- Ability to convey results of inquiry through written communication (letter, fax, e-mail) or verbal communication (telephone).

Medical & Billing Terminology
- Understanding of medical terminology used in claims documentation.
- Working knowledge of Medicaid and Medicare benefits.
- Familiarity with claims medical coding.
- Knowledge of the different standard claims forms used for physician and hospital billing.
- Understand COB and LTC processes.
- Knowledge of state and/or federal guidelines that apply to the Medicaid or Medicare benefits.
- Understand the different levels of care and applicable payment methodology.

Claims System Familiarity
- Understanding of the claims payment system.
- Ability to access documentation through the use of an image repository-review system, such as Macess.
- Ability to apply multiple market information and process high dollar claims due to authorization level
- High level understanding of system configuration for benefits, pricing, and provider set up.
- Ability to identify system issues to management for problem solving.

Behavioral Competencies

Strategic Leadership

Be Strategic
- Demonstrates understanding of the organization's mission and strategies.
- Works to clarify and understand the broader purpose and mission of own work.
- Integrates and balances big-picture concerns with day-to-day activities.
- Generates innovative ideas and solutions to problems.
- Identifies opportunities to increase efficiency, simplicity, and revenue.

Make Sound Decisions
- Approaches problems with curiosity and open-mindedness.
- Collects sufficient information to understand problems and issues.
- Analyzes problems and issues from different points of view.
- Applies accurate logic and common sense in making decisions.

People Leadership

Develop/Support Organizational Talent
- Relates to people in an open, friendly, and accepting manner.
- Treats others with respect.
- Listens carefully and attentively to others’ opinions and ideas.
- Maintains positive relationships even under difficult or heated circumstances.
- Works cooperatively with people from different cultural backgrounds.

Ensure Collaboration
- Encourages people to draw on each other's strengths and experience to work together effectively, within and across teams.
- Appropriately involves others in decisions and plans that affect them.
- Provides honest, helpful feedback to others on their performance.
- Shares own experience and expertise with others.

Results Leadership

Show Drive and Initiative
- Demonstrates a "can-do" spirit, a sense of optimism, ownership, and commitment.
- Maintains a consistent, high level of productivity.
- Takes personal responsibility to make decisions and take action.
- Does not easily give up in the face of unexpected obstacles.
- Projects a positive image and serves as a role model for others.

Accountability / Optimize Execution
- Juggles many priorities and competing demands for one's time.
- Acts resourcefully to ensure that work is completed within specified time and quality parameters.
- Removes obstacles in order to move the work forward and/or get efforts back on track.
- Surfaces problems and issues before projects get derailed.

PHYSICAL REQUIREMENTS

The physical requirements described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Must be able to operate general office equipment including but not limited to: computer, phones and related media and information devices.
- Ability to communicate both in person and/or by telephone.
- Must be able to travel as needed and adhere to Amerigroup travel policies and procedures.

ermCS
]]>Tue, 14 May 2013 00:00:00 GMThttp://www.amerigroup-jobs.com/job/San-Antonio-Claims-Resolution-Analyst-Job-TX-78201/2597172/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSShttp://www.amerigroup-jobs.com/job/San-Antonio-Claims-Resolution-Analyst-Job-TX-78201/2597172/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS
Job ID 2013-22412 # Positions 1
Location US-TX-Austin
Search Category Health Care Operations
Type Regular Full-Time (30+ hours) Posted Date 3/31/2013
Additional Locations ..

More information about this job:
Summary:

Responsible for member retention by investigating and leading the resolution of member complaints. Serve as a liaison/mediator between member, the provider and Plan, Provide education to the member on Medicaid Managed Care and their benefits with AMERIGROUP, informing and ensuring that members are aware of their rights and responsibilities, the complaint process, and health education activities available in the community. Support member outreach activities.

Responsibilities:

1. Investigate, resolve, and document member complaints in accordance with AMERIGROUP policies and State requirements.

2. Conduct out-of office / home visits with members to educate and advise on AMERIGROUP programs, policy, and benefits as appropriate.

3. Investigate and resolve issues regarding members with non-compliant, behavioral, and abusive conduct identified by providers. Work with law enforcement officials as appropriate.

4. Conduct member interviews to ensure that members are informed of their rights and responsibilities.

5. Assist with member education related to prevention, outreach and education programs.

6. Identify members to participate on Plan committees.

7. Assist member as needed, including locating a PCP, obtaining medical records, obtaining transportation, and completing required forms. Resolution and coordination in barriers to care needs.

8. Assist in the preparation for a Grievance Panel, assuring member participation and explaining the process to the member.

9. Review complaint reports for accuracy and completeness and ensure required reports meet timely filing requirements.

10. Participate on the weekly complaint review committee as appropriate.

11. Assist in the maintenance of the complaint database.

12. Prepare additional reports and presentations as needed to support community relations, Provider Services and member education activities.

13. Attend community events as appropriate.

14. Track, trend, and report quality and access complaints by provider. Coordinate with provider relations for follow-up of issues identified.

15. Act as member advocate with providers, CBO’s, and AMERIGROUP associates as indicated.

16. Serve as liaison with state hot line staff and internal compliance personnel.

17. Work with other AMERIGROUP departments and with physicians to resolve member issues.

18. Establish and maintain working relationships with member advocacy groups.

19. Other duties as assigned.

Qualifications:

EDUCATION AND EXPERIENCE

Education

Required:
- Two-year degree in a related field or; 3 – 5 years experience in a social or health related service-oriented industry.

Years and Type of Experience Required:

Required:
- 3 – 5 years experience in a social or health related service-oriented industry.
- Experience with complaint/grievance processes.

Preferred:
- Previous experience in a Medicaid Managed Care Health Plan.
- Successful record of community volunteer work.
- Previous experience in outreach to members to include resolution of issues.

Specific Technical Skills

Required:
- Excellent interpersonal, organizational, problem solving, multitasking, analytical and communication skills.
- Excellent Customer Service skills.
- Appreciation of cultural diversity and sensitivity towards target population.
- Professional telephone etiquette.
- Strong mediation skills.
- Ability to work calmly and effectively under adverse conditions.
- Computer keyboard and word processing proficiency.

LANGUAGE SKILLS

Prefered:
- Bi-lingual

Certifications or Licensure

Required:
- Must possess a valid driver’s license and required insurance.

Other:

Required:
- Ability to work evenings and weekends as needed.

Preferred:
- Established working relationships with Community Based Organizations.

PHYSICAL REQUIREMENTS
- Must be able to operate a computer.
- Must be able to operate a telephone.
- Local travel required - must be able to travel locally to physician offices and members homes.
- Must be able to communicate verbally.
- Must be able to tolerate standing and sitting for long periods of time.
- Must be able to operate a motor vehicle.

ermHO
]]>Mon, 29 Apr 2013 03:01:00 GMThttp://www.amerigroup-jobs.com/job/Austin-QM-Membr-Advocate-Job-TX-73301/2521543/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSShttp://www.amerigroup-jobs.com/job/Austin-QM-Membr-Advocate-Job-TX-73301/2521543/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS
Job ID 2013-22804 # Positions 1
Location US-IN-Indianapolis
Search Category Legal
Type Regular Full-Time (30+ hours) Posted Date 5/9/2013
Additional Locations ..

More information about this job:
Summary:

The Compliance Officer (CO) is responsible for implementing the Corporate Compliance Program (CCP) at the health plan level that serves to prevent and detect crime, to promote compliance with corporate policies and upholds an ethical culture. Additionally, the individual in this role will be responsible for developing and implementing specifically-tailored compliance education sessions to address key issues; and for designing and implementing a compliance communication strategy to keep senior management and other relevant associates informed of changes to the regulatory environment within the scope of the CCP, as well as communicating about specific compliance program initiatives throughout the year.

Responsibilities:

1. Establish scope of activities required to support the Compliance Effectiveness Review at the Plan Compliance Officer (PCO) level.

2. Lead and assure compliance training activities are completed in an effective manner.

3. Monitor health Plan Performance Standards for compliance with contractual and regulatory requirements and maintain a general focus on call center metrics, claims payments, minimum net worth and licensure of health plans and employed professional.

4. Maintain relevant Plan Policies and Procedures that may impact the Plan or Company and provide assessments to critical stakeholders and Plan senior leadership on consistency with regulatory and contractual requirements including anti-kickback statutes, timeliness of enrollment; and incentive compensation.

5. Review policies and procedures and health plan activities to ensure adherence to Business Associate requirements and physical and electronic security under HIPAA.

6. Ensure regular meetings of the Plan Compliance Committee (PCC) to discuss identification and assessment of compliance initiatives, potential risks and current state.

7. Serve as liaison to external and internal audits between business owner and state/federal entities:

a. Coordinate with OBE on preliminary investigations of potential non-compliance; maintain confidentiality as appropriate and recommend corrective action or next steps to OBE and business owners;

b. Monitor payments or contributions to providers and community and faith based organizations made by or on behalf of the health plan to ensure compliance with AGP’s policies and procedures including but not limited to charitable donations and gifts;

c. Maintain a quarterly log of marketing materials reviewed via CMAP, submitted to the governing agency and approved for use and perform monthly reviews of marketing field activities to ensure compliance;

d. Monitor and evaluate member access through review of changes in network composition and appointment guideline surveys; and

e. Verify control process used to ensure accuracy of information submitted to government agencies.

8. Establish schedule to monitor corrective actions related to issues identified at the PCC level.

9. Attend and participate in meetings where business strategy is discussed with Plan senior leadership.

10. Provide regular and ad hoc reports on activities outlined above for review by the OBE and health plan CEO/EVP.

11. Other Duties as assigned.

Qualifications:

EDUCATION AND EXPERIENCE

Education

Required:
- Bachelors degree from an accredited university.

Preferred:
- Masters or higher degree in Law, Business, Healthcare.

Years and Type of Experience Required:

Required:
- Minimum of 7 years relevant experience in healthcare compliance, audit or compliance, with at least 3 years of leadership/management experience.

Preferred:
- Experience in conducting or responding to government audits and investigations, and/or direct experience working in a relevant federal agency(HHS, OIG, CMS).

Specific Technical Skills

Required:
- Proficient in the use of MS Office (Visio, Excel, Access, Word).

Certifications or Licensure

Required:
- N/A

Preferred:
- CHC, Current license to practice law in at least one state, CPA or CIA.

Other:

Required:
- Excellent verbal and written communication skills; Solid analytical skills and knowledge of controls.
- Strong leadership skills with the ability to influence and manage.

SCOPE INFORMATION

# Direct Reports: 0

# Indirect Reports: 0-5

Budgetary $ Responsibility: Areas of Responsibility

PHYSICAL REQUIREMENTS
- Must be able to operate a computer and telephone.
- Travel 30% on common carriers and adhere to AMERIGROUP travel policies.

ermCorp
]]>Thu, 09 May 2013 00:00:00 GMThttp://www.amerigroup-jobs.com/job/Indianapolis-Director-Compliance-Offcr-Plan-Job-IN-46201/2589880/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSShttp://www.amerigroup-jobs.com/job/Indianapolis-Director-Compliance-Offcr-Plan-Job-IN-46201/2589880/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS
Job ID 2013-22808 # Positions 1
Location US-VA-Richmond
Search Category Legal
Type Regular Full-Time (30+ hours) Posted Date 5/9/2013
Additional Locations ..

More information about this job:
Summary:

The Compliance Officer (CO) is responsible for implementing the Corporate Compliance Program (CCP) at the health plan level that serves to prevent and detect crime, to promote compliance with corporate policies and upholds an ethical culture. Additionally, the individual in this role will be responsible for developing and implementing specifically-tailored compliance education sessions to address key issues; and for designing and implementing a compliance communication strategy to keep senior management and other relevant associates informed of changes to the regulatory environment within the scope of the CCP, as well as communicating about specific compliance program initiatives throughout the year.

Responsibilities:

1. Establish scope of activities required to support the Compliance Effectiveness Review at the Plan Compliance Officer (PCO) level.

2. Lead and assure compliance training activities are completed in an effective manner.

3. Monitor health Plan Performance Standards for compliance with contractual and regulatory requirements and maintain a general focus on call center metrics, claims payments, minimum net worth and licensure of health plans and employed professional.

4. Maintain relevant Plan Policies and Procedures that may impact the Plan or Company and provide assessments to critical stakeholders and Plan senior leadership on consistency with regulatory and contractual requirements including anti-kickback statutes, timeliness of enrollment; and incentive compensation.

5. Review policies and procedures and health plan activities to ensure adherence to Business Associate requirements and physical and electronic security under HIPAA.

6. Ensure regular meetings of the Plan Compliance Committee (PCC) to discuss identification and assessment of compliance initiatives, potential risks and current state.

7. Serve as liaison to external and internal audits between business owner and state/federal entities:

a. Coordinate with OBE on preliminary investigations of potential non-compliance; maintain confidentiality as appropriate and recommend corrective action or next steps to OBE and business owners;

b. Monitor payments or contributions to providers and community and faith based organizations made by or on behalf of the health plan to ensure compliance with AGP’s policies and procedures including but not limited to charitable donations and gifts;

c. Maintain a quarterly log of marketing materials reviewed via CMAP, submitted to the governing agency and approved for use and perform monthly reviews of marketing field activities to ensure compliance;

d. Monitor and evaluate member access through review of changes in network composition and appointment guideline surveys; and

e. Verify control process used to ensure accuracy of information submitted to government agencies.

8. Establish schedule to monitor corrective actions related to issues identified at the PCC level.

9. Attend and participate in meetings where business strategy is discussed with Plan senior leadership. 10. Provide regular and ad hoc reports on activities outlined above for review by the OBE and health plan CEO/EVP.

11. Other Duties as assigned.

Qualifications:

EDUCATION AND EXPERIENCE

Education

Required:
- Bachelors degree from an accredited university.

Preferred:
- Masters or higher degree in Law, Business, Healthcare.

Years and Type of Experience Required:

Required:
- Minimum of 7 years relevant experience in healthcare compliance, audit or compliance, with at least 3 years of leadership/management experience.

Preferred:
- Experience in conducting or responding to government audits and investigations, and/or direct experience working in a relevant federal agency(HHS, OIG, CMS).

Specific Technical Skills

Required:
- Proficient in the use of MS Office (Visio, Excel, Access, Word).

Certifications or Licensure

Required:
- N/A

Preferred:
- CHC, Current license to practice law in at least one state, CPA or CIA.

Other:

Required:
- Excellent verbal and written communication skills; Solid analytical skills and knowledge of controls.
- Strong leadership skills with the ability to influence and manage.

SCOPE INFORMATION

# Direct Reports: 0

# Indirect Reports: 0-5

Budgetary $ Responsibility: Areas of Responsibility

PHYSICAL REQUIREMENTS
- Must be able to operate a computer and telephone.
- Travel 30% on common carriers and adhere to AMERIGROUP travel policies.

ermCorp
]]>Thu, 09 May 2013 00:00:00 GMThttp://www.amerigroup-jobs.com/job/Richmond-Director-Compliance-Offcr-Plan-Job-VA-23173/2589882/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSShttp://www.amerigroup-jobs.com/job/Richmond-Director-Compliance-Offcr-Plan-Job-VA-23173/2589882/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS
Job ID 2013-22803 # Positions 1
Location US-CA-Thousand Oaks
Search Category Legal
Type Regular Full-Time (30+ hours) Posted Date 5/10/2013
Additional Locations ..

More information about this job:
Summary:

The Associate Vice President, Compliance Officer (AVP, PCO) is responsible for implementing the Corporate Compliance Program (CCP) at the health plan level that serves to prevent and detect crime, to promote compliance with corporate policies and upholds an ethical culture. Additionally, the individual in this role will be responsible for developing and implementing specifically-tailored compliance education sessions to address key issues; and for designing and implementing a compliance communication strategy to keep senior management and other relevant associates informed of changes to the regulatory environment within the scope of the CCP, as well as communicating about specific compliance program initiatives throughout the year.

Responsibilities:

1. Establish scope of activities required to support the Compliance Effectiveness Review at the Plan Compliance Officer (PCO) level.

2. Lead and assure compliance training activities are completed in an effective manner.

3. Monitor health Plan Performance Standards for compliance with contractual and regulatory requirements and maintain a general focus on call center metrics, claims payments, minimum net worth and licensure of health plans and employed professional.

4. Maintain relevant Plan Policies and Procedures that may impact the Plan or Company and provide assessments to critical stakeholders and Plan senior leadership on consistency with regulatory and contractual requirements including anti-kickback statutes, timeliness of enrollment; and incentive compensation.

5. Review policies and procedures and health plan activities to ensure adherence to Business Associate requirements and physical and electronic security under HIPAA.

6. Ensure regular meetings of the Plan Compliance Committee (PCC) to discuss identification and assessment of compliance initiatives, potential risks and current state.

7. Serve as liaison to external and internal audits between business owner and state/federal entities:

a. Coordinate with OBE on preliminary investigations of potential non-compliance; maintain confidentiality as appropriate and recommend corrective action or next steps to OBE and business owners.

b. Monitor payments or contributions to providers and community and faith based organizations made by or on behalf of the health plan to ensure compliance with AGP’s policies and procedures including but not limited to charitable donations and gifts.

c. Maintain a quarterly log of marketing materials reviewed via CMAP, submitted to the governing agency and approved for use and perform monthly reviews of marketing field activities to ensure compliance.

d. Monitor and evaluate member access through review of changes in network composition and appointment guideline surveys.

e. Verify control process used to ensure accuracy of information submitted to government agencies;

8. Establish schedule to monitor corrective actions related to issues identified at the PCC level.

9. Attend and participate in meetings where business strategy is discussed with Plan senior leadership.

10. Provide regular and ad hoc reports on activities outlined above for review by the OBE and health plan CEO/EVP. 11. Other Duties as assigned.

Qualifications:

EDUCATION AND EXPERIENCE

Education

Required:
- Bachelors degree from an accredited university Preferred: Masters or higher degree in Law, Business, Healthcare.

Years and Type of Experience Required:

Required:
- Minimum of 10 years relevant experience in healthcare compliance, audit or compliance, with at least 5 years of leadership/management experience.

Preferred:
- Experience in conducting or responding to government audits and investigations, and/or direct experience working in a relevant federal agency(HHS, OIG, CMS).
- Experience working with markets that have a vast geographic area including multiple offices.
- Experience with working with more heavily regulated markets, i.e. markets that have multiple agencies providing oversight.

Specific Technical Skills

Required:
- Proficient in the use of MS Office (Visio, Excel, Access, Word)

Certifications or Licensure

Preferred:
- CHC, Current license to practice law in at least one state, CPA or CIA

Other:

Required:
- Excellent verbal and written communication skills; Solid analytical skills and knowledge of controls.
- Strong leadership skills with the ability to influence and manage.

SCOPE INFORMATION

# Direct Reports: 0

# Indirect Reports: 0-5

Budgetary $ Responsibility:

PHYSICAL REQUIREMENTS
- Must be able to operate a computer and telephone.
- Travel 30% on common carriers and adhere to AMERIGROUP travel policies.

ermCorp
]]>Fri, 10 May 2013 00:00:00 GMThttp://www.amerigroup-jobs.com/job/Thousand-Oaks-AVP-Compliance-Officer-Plan-Job-CA-91319/2592116/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSShttp://www.amerigroup-jobs.com/job/Thousand-Oaks-AVP-Compliance-Officer-Plan-Job-CA-91319/2592116/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS
Job ID 2013-22859 # Positions 1
Location US-NATIONWIDE
US-GA-Atlanta
Search Category Legal
Type Regular Full-Time (30+ hours) Posted Date 5/14/2013
Additional Locations US-GA-Atlanta

More information about this job:
Summary:

The Compliance Officer (CO) is responsible for implementing the Corporate Compliance Program (CCP) at the health plan level that serves to prevent and detect crime, to promote compliance with corporate policies and upholds an ethical culture. Additionally, the individual in this role will be responsible for developing and implementing specifically-tailored compliance education sessions to address key issues; and for designing and implementing a compliance communication strategy to keep senior management and other relevant associates informed of changes to the regulatory environment within the scope of the CCP, as well as communicating about specific compliance program initiatives throughout the year.

Responsibilities:

1. Establish scope of activities required to support the Compliance Effectiveness Review at the Plan Compliance Officer (PCO) level.

2. Lead and assure compliance training activities are completed in an effective manner.

3. Monitor health Plan Performance Standards for compliance with contractual and regulatory requirements and maintain a general focus on call center metrics, claims payments, minimum net worth and licensure of health plans and employed professional.

4. Maintain relevant Plan Policies and Procedures that may impact the Plan or Company and provide assessments to critical stakeholders and Plan senior leadership on consistency with regulatory and contractual requirements including anti-kickback statutes, timeliness of enrollment; and incentive compensation.

5. Review policies and procedures and health plan activities to ensure adherence to Business Associate requirements and physical and electronic security under HIPAA.

6. Ensure regular meetings of the Plan Compliance Committee (PCC) to discuss identification and assessment of compliance initiatives, potential risks and current state.

7. Serve as liaison to external and internal audits between business owner and state/federal entities:

a. Coordinate with OBE on preliminary investigations of potential non-compliance; maintain confidentiality as appropriate and recommend corrective action or next steps to OBE and business owners;

b. Monitor payments or contributions to providers and community and faith based organizations made by or on behalf of the health plan to ensure compliance with AGP’s policies and procedures including but not limited to charitable donations and gifts;

c. Maintain a quarterly log of marketing materials reviewed via CMAP, submitted to the governing agency and approved for use and perform monthly reviews of marketing field activities to ensure compliance;

d. Monitor and evaluate member access through review of changes in network composition and appointment guideline surveys; and

e. Verify control process used to ensure accuracy of information submitted to government agencies.

8. Establish schedule to monitor corrective actions related to issues identified at the PCC level.

9. Attend and participate in meetings where business strategy is discussed with Plan senior leadership.

10. Provide regular and ad hoc reports on activities outlined above for review by the OBE and health plan CEO/EVP.

11. Other Duties as assigned.

Qualifications:

EDUCATION AND EXPERIENCE

Education

Required:
- Bachelors degree from an accredited university.

Preferred:
- Masters or higher degree in Law, Business, Healthcare.

Years and Type of Experience Required:

Required:
- Minimum of 7 years relevant experience in healthcare compliance, audit or compliance, with at least 3 years of leadership/management experience.

Preferred:
- Experience in conducting or responding to government audits and investigations, and/or direct experience working in a relevant federal agency(HHS, OIG, CMS).

Specific Technical Skills

Required:
- Proficient in the use of MS Office (Visio, Excel, Access, Word).

Certifications or Licensure

Required:
- N/A

Preferred:
- CHC, Current license to practice law in at least one state, CPA or CIA.

Other:

Required:
- Excellent verbal and written communication skills; Solid analytical skills and knowledge of controls.
- Strong leadership skills with the ability to influence and manage.

SCOPE INFORMATION

# Direct Reports: 0

# Indirect Reports: 0-5

Budgetary $ Responsibility: Areas of Responsibility

PHYSICAL REQUIREMENTS
- Must be able to operate a computer and telephone.
- Travel 30% on common carriers and adhere to AMERIGROUP travel policies.

ermCorp
]]>Tue, 14 May 2013 00:00:00 GMThttp://www.amerigroup-jobs.com/job/Director-Compliance-Officer-Plan-this-position-is-location-in-Georgia-Job/2597174/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSShttp://www.amerigroup-jobs.com/job/Director-Compliance-Officer-Plan-this-position-is-location-in-Georgia-Job/2597174/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS
Job ID 2013-22366 # Positions 1
Location US-TX-Houston
Search Category Health Care Operations
Type Regular Full-Time (30+ hours) Posted Date 3/21/2013
Additional Locations ..

More information about this job:
Summary:

As a leader in a service operations environment consisting of claims processing and customer service, responsible for developing and implementing policies, procedures and processes to meet the needs of the customer, internal and external, consistent with State and Federal requirements. Ensure the achievement of all performance goals, adherence to regulatory requirements, coordination of all operational activities and implementation of operational processes. Manages the achievement and maintenance of all performance goals for the teams within their span of control, and contributes towards the attainment of Claims and Customer Service goals and objectives.

This role will lead our claims department. Claims background is preferred.

Responsibilities:

1. Translates business vision and strategy into operational tactics building organizational support and infrastructure needed.

2. Sets strategies, goals, programs, best practices and compliance improvement projects for each assigned market improving operational execution and delivering on our value proposition to customers and members.

3. Develops a high performing team through individual and team development in order to achieve established performance standards for the department.

4. Ensures staff is scheduled appropriately to manage inventories.

5. Ensures that operations achieve all regular established and internal operating metrics.

6. Provides senior level guidance and support in the development and management of customer relationships.

7. Coordinates the resolution and communication of all customer service issues presented by health plans or management.

8. Establishes and maintains appropriate internal controls and effective performance reporting systems.

9. Collaborates with internal partners to develop process improvement initiatives to reduce defects, improve transactional accuracy, and improve overall operating efficiencies.

10. Meets fiduciary responsibility by maximizing dollar recovery, where appropriate, through the appropriate channels, e.g. cost containment.

11. Assesses operating business risks/opportunities and identify strategies to mitigate/capitalize as appropriate.

12. Directs due diligence and integration of new business.

13. Performs other duties as assigned or requested.

Qualifications:

EDUCATION AND EXPERIENCE

Education

Required:
- Bachelor’s degree, or equivalent experience.

Preferred:
- Bachelor’s degree or higher in Business, Healthcare Administration or a related field.

Years and Type of Experience Required:

Required:
- Seven years of relevant experience and three years in a leadership capacity leading and managing direct reports.
- Demonstrated ability to quickly grasp new concepts.

Preferred:
- Prior experience with Medicaid and Medicare administration and regulations.
- Prior experience managing in an operations, call center or claims environment.
- Prior leadership experience in a healthcare environment.

Certifications or Licensures

Required:
- None

Preferred:
- Six Sigma trained (Green Belt certification is a plus)

Language Skills

Required:
- English

Technical Competencies

Computer Skills and Office Equipment
- Ability to use software and hardware of a computer to complete certain moderately-complex to complex tasks.
- Able to use basic office equipment such as telephone, fax machine and copy machine.
- Working knowledge in a windows environment to include navigation skills using a mouse, keyboard and 10 key.
- Use of internet, familiarity with SharePoint sites.
- Ability to review and draft correspondence in email system and word processing systems.
- Ability to use software for data analysis, reporting and sharing of information to problem solve.
- Ability to create and manipulate spreadsheets (i.e., data entry and format cells).
- Ability to work in databases.

Office Math Skills
- Ability to process numbers, which is an essential skill for any problem solving situation in a claims environment.
- Skills in the use of a calculator (using percentages, multiplication and division) to determine appropriate benefit payment.
- Ability to calculate the manual pricing of claims. Skills to verify accuracy with visual percentage calculations.

Read, Interpret and Apply Information
- Ability to research information using available resources.
- Read and comprehend the information to analyze and apply logical thinking in making sound decisions.
- Understand and apply general instructions to appropriately and accurately process claims.
- Capacity to follow step-by-step and general directions, remain detail oriented and verify data including HIPAA documentation.
- Ability to investigate and review claim from initial receipt.
- Ability to apply in-depth problem solving with more complex claims.
- Ability to read and interpret contracts for outpatient and inpatient claims.
- Ability to prepare written communication to providers documenting the results of their inquiry.
- Ability to convey results of inquiry through written communication (letter, fax, e-mail) or verbal communication (telephone).

Medical & Billing Terminology
- Understanding of medical terminology used in claims documentation.
- Working knowledge of Medicaid and Medicare benefits.
- Familiarity with claims medical coding.
- Knowledge of the different standard claims forms used for physician and hospital billing.
- Understand COB and LTC processes.
- Knowledge of state and/or federal guidelines that apply to the Medicaid or Medicare benefits.
- Understand the different levels of care and applicable payment methodology.

Claims System Familiarity
- Understanding of the claims payment system.
- Ability to access documentation through the use of an image repository-review system, such as Macess.
- Ability to apply multiple market information and process high dollar claims due to authorization level.
- High level understanding of system configuration for benefits, pricing, and provider set up.
- Ability to identify system issues to management for problem solving.

Behavioral Competencies

Strategic Leadership

Be Strategic
- Integrates and balances big-picture concerns with day-to-day activities.
- Conveys a thorough understanding of own area's strengths, weaknesses, opportunities, and threats.
- Evaluates and pursues initiatives, investments, and opportunities based on their fit with broader strategies.
- Stays abreast of key competitor actions and their implications or threats to the business.

Make Sound Decisions
- Focuses on important information without getting bogged down in unnecessary detail.
- Probes and looks past symptoms to determine the underlying causes of problems and issues.
- Brings to bear the appropriate knowledge, information, and expertise in making decisions.

People Leadership Develop / Support Organizational Talent
- Identifies the qualifications required for successful job performance.
- Provides honest, helpful feedback to others on their performance.
- Helps others identify and prioritize their development objectives.
- Promotes sharing of expertise and a free flow of learning across the organization.

Ensure Collaboration
- Discourages "we vs. they" thinking.
- Appropriately involves others in decisions and plans that affect them.
- Works to remove barriers to collaboration.
- Seeks to understand and address the concerns and interests of others with opposing viewpoints.

Results Leadership Show Drive and Initiative
- Does not easily give up in the face of unexpected obstacles.
- Sets high standards of performance for self and others.
- Puts in extra effort and work to accomplish critical or difficult tasks.
- Tackles tough challenges or problems quickly and directly.

Accountability/Optimize Execution
- Conveys clear expectations for assignments.
- Delegates assignments to the lowest appropriate level.
- Monitors progress of others and redirects efforts when goals change or are not met.
- Holds people accountable for achieving their goals.

SCOPE INFORMATION

# Direct Reports: 5-8

# Indirect Reports: 100-160+

Budgetary $ Responsibility: $5m to $16m (Shared responsibility of department budget).

PHYSICAL REQUIREMENTS

The physical requirements described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Must be able to operate general office equipment including but not limited to: computer, phones and related media and information devices.
- Ability to communicate both in person and/or by telephone.
- Must be able to travel as needed and adhere to Amerigroup travel policies and procedures.

ermHO
]]>Sat, 18 May 2013 05:31:00 GMThttp://www.amerigroup-jobs.com/job/Houston-Director-Service-Operations-%28Claims-Dept%29-Job-TX-77001/2494366/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSShttp://www.amerigroup-jobs.com/job/Houston-Director-Service-Operations-%28Claims-Dept%29-Job-TX-77001/2494366/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS
Job ID 2013-22674 # Positions 1
Location US-TX-Houston
Search Category Customer Service
Type Regular Full-Time (30+ hours) Posted Date 4/24/2013
Additional Locations ..

More information about this job:
Summary:

Provides leadership and day-to-day direction for production-related claims activities across all markets within the claims department, to include: claims processing and payment, management reporting and management and development of staff. Develops and implements policies, procedures and processes that ensure the timely payment of claims in accordance with contractual, State and Federal requirements.

Responsibilities:

1. Evaluates and manages all daily activities and issues involving the accurate and timely processing of claims within state and federal requirements and performance guarantees for assigned markets/products. Sets goals to meet and exceed customer expectations.

2. Manages the day-to-day activities of assigned associates, supervises staff creating development plans for associates, providing timely and effective feedback, and develops corrective action plans when needed.

3. Develops strong relationships with internal/external partners, practicing excellent customer relations and attention to customer needs.

4. Ensures the preparation and analysis of all standard claim reports as requested (i.e. aging, contact logs, quality reports and action grams, etc).

5. Monitors claims processing activities to ensure that the organization’s service, quality, productivity and financial standards or goals are achieved.

6. Develops policies, procedures and processes to ensure the successful implementation of new or revised contracts in accordance with Federal, State and other regulatory agency requirements.

7. Serves as the department expert for the Health Plan in the areas of provider billing, provider reimbursement and benefits. Interprets contract language and rates and coordinates with other internal customers to ensure the accuracy of system configuration and claims processing.

8. Reviews and responds to all regulatory updates and ensures all statistical performance reports are generated within the required time frames.

9. Initiates and leads communication with claims teams and other functional areas to ensure resolution to issues and provide long-term solutions.

10. Assists with meeting budget and understanding capacity model/management for assigned markets to effectively and appropriately staff for claim volume.

11. Adheres to and manages to ensure the adherence to all Amerigroup and department policies and procedures, as well as HIPAA regulations.

12. Develops and implements process improvements with high impact to increase/improve productivity and quality results within the department.

13. Performs other duties as assigned or requested.

Qualifications:

EDUCATION AND EXPERIENCE

Education

Required:
- Bachelor’s degree in related field or equivalent experience.

Years and Type of Experience Required:

Required:
- Five years of experience in health care claims administration or in a health care insurance company management capacity with at least one year of leadership/supervisory experience.

Internal candidates:
- Demonstrated proficiency and two years experience as a Supervisor/Manager within the company.
- Successful completion of Amerigroup Leadership Development Program in lieu of above years of experience.

Preferred:
- Claims processing experience.

Language Skills

Required:
- English

Technical Competencies Computer Skills and Office Equipment
- Ability to use software and hardware of a computer to complete certain moderately-complex to complex tasks.
- Able to use basic office equipment such as telephone, fax machine and copy machine.
- Working knowledge in a windows environment to include navigation skills using a mouse, keyboard and 10 key.
- Use of internet, familiarity with SharePoint sites.
- Ability to review and draft correspondence in email system and word processing systems.
- Ability to use software for data analysis, reporting and sharing of information to problem solve.
- Ability to create and manipulate spreadsheets (i.e., data entry and format cells). - Ability to work in databases.

Office Math Skills
- Ability to process numbers, which is an essential skill for any problem solving situation in a claims environment.
- Skills in the use of a calculator (using percentages, multiplication and division) to determine appropriate benefit payment.
- Ability to calculate the manual pricing of claims. Skills to verify accuracy with visual percentage calculations. Read, Interpret and Apply information
- Ability to research information using available resources.
- Read and comprehend the information to analyze and apply logical thinking in making sound decisions.
- Understand and apply general instructions to appropriately and accurately process claims.
- Capacity to follow step-by-step and general directions, remain detail oriented and verify data including HIPAA documentation.
- Ability to investigate and review claim from initial receipt.
- Ability to apply in-depth problem solving with more complex claims.
- Ability to read and interpret contracts for outpatient and inpatient claims.
- Ability to prepare written communication to providers documenting the results of their inquiry.
- Ability to convey results of inquiry through written communication (letter, fax, e-mail) or verbal communication (telephone).

Medical & Billing Terminology
- Understanding of medical terminology used in claims documentation.
- Working knowledge of Medicaid and Medicare benefits.
- Familiarity with claims medical coding.
- Knowledge of the different standard claims forms used for physician and hospital billing.
- Understand COB and LTC processes.
- Knowledge of state and/or federal guidelines that apply to the Medicaid or Medicare benefits.
- Understand the different levels of care and applicable payment methodology.

Claims System Familiarity
- Understanding of the claims payment system.
- Ability to access documentation through the use of an image repository-review system, such as Macess.
- Ability to apply multiple market information and process high dollar claims due to authorization level.
- High level understanding of system configuration for benefits, pricing, and provider set up.
- Ability to identify system issues to management for problem solving.

Behavioral Competencies

Strategic Leadership

Be Strategic
- Demonstrates understanding of the organization's mission and strategies.
- Sees the "big picture" (e.g., overall themes, trends, goals).
- Integrates and balances big-picture concerns with day-to-day activities.
- Establishes strategies for achieving individual or work unit goals.

Make Sound Decisions
- Analyzes, incorporates and applies new information and concepts.
- Recognizes symptoms that indicate problems.
- Makes sound decisions on everyday issues and problems.
- Makes timely decisions on problems/issues requiring immediate attention.

People Leadership Develop/Support Organizational Talent
- Identifies and recruits/refers qualified people.
- Makes accurate evaluations of people's capabilities and fit.
- Provides honest, helpful feedback to others on their performance.
- Shares own experience and expertise with others.

Ensure Collaboration
- Provides sound rationale for recommendations.
- Solicits support for ideas.
- Ensures that own positions address others' needs and priorities.
- Builds relationships to create a foundation for future influence.

Results Leadership Show Drive and Initiative
- Identifies what needs to be done and does it.
- Maintains a consistent, high level of productivity.
- Takes personal responsibility to make decisions and take action.
- Does not easily give up in the face of unexpected obstacles.

Accountability / Optimize Execution
- Juggles many priorities and competing demands for one's time.
- Conveys clear expectations for assignments.
- Removes obstacles in order to move the work forward and/or get efforts back on track.
- Seeks additional resources to complete tasks when needed.

SCOPE INFORMATION

# Direct Reports: 15-25

# Indirect Reports: 0

Budgetary $ Responsibility: N/A

PHYSICAL REQUIREMENTS

The physical requirements described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Must be able to operate general office equipment including but not limited to: computer, phones and related media and information devices.
- Ability to communicate both in person and/or by telephone.
- Must be able to travel as needed and adhere to AMERIGROUP travel policies and procedures.

ermCS
]]>Wed, 24 Apr 2013 00:00:00 GMThttp://www.amerigroup-jobs.com/job/Houston-Mgr-Claims-Job-TX-77001/2564571/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSShttp://www.amerigroup-jobs.com/job/Houston-Mgr-Claims-Job-TX-77001/2564571/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS
Job ID 2013-22899 # Positions 40
Location US-TX-Houston
Search Category Customer Service
Type Regular Full-Time (30+ hours) Posted Date 5/17/2013
Additional Locations ..

More information about this job:
Summary:

Associates are focused on understanding and meeting the needs of our customers by connecting with the mission and vision in their daily work activity. Claims associates are not only processors, but are challenged to use their analytical skills to identify issues and proactively engage to solve problems that may negatively impact our customers. While anticipating the needs of our customers, Claims associates will be skilled in the uniqueness of their markets to insure that every claim is handled appropriately and accurately, with the goal of “treating each claim as a member”. While meeting production goals is important and necessary, at Amerigroup, Claims associates will connect their work with the impact on our customers to create an amazing customer experience.

If you are looking for a way to make a difference in the lives of others by offering a little help to those in need, you are invited to further explore employment opportunities at Amerigroup.

Under general supervision, analysts evaluate simple to moderately complex claims to determine the type and amounts of benefits payable. You will perform all authorized duties in the processing of claims allocated to the assigned market consistent with all applicable company and departmental policies.

This requisition is posted for candidates interested in a training class to start Summer 2013 in Houston.

Responsibilities:

1. Researches and processes all intermediate level claims transactions. Processing includes most claim types with the exception of inpatient, transplant, dialysis and hospice.

2. Processes correspondence and customer service inquiries as it relates to the above claims transactions.

3. Processes primary care encounter information and fee for service claims received in both paper and automated formats into claims systems.

4. Accurately interprets, understands and applies product contracts and fee schedules for assigned markets when processing claims.

5. Interprets and applies explanation of benefits (EOB) statements from other carrier to faciliatate coordination of coverage.

6. Meets or exceeds established quality and production standards.

7. Reviews and responds to quality audits.

8. Responds timely to quality error assignments and provide appropriate documentation to support actions.

9. Performs other duties as assigned.

Qualifications:

EDUCATION AND EXPERIENCE

Education

Required:
- High school diploma or GED.

Preferred:
- Associate’s degree in business or health care field.
- Claims processing/coding certificate program.

Years and Type of Experience Required:

Required:
- One year experience in production or office environment.

Preferred:
- Two years of claims processing experience.

Language Skills

Required:
- English

Technical Competencies

Computer Skills and Office Equipment
- Ability to use software and hardware of a computer to complete certain moderately-complex to complex tasks.
- Able to use basic office equipment such as telephone, fax machine and copy machine.
- Working knowledge in a windows environment to include navigation skills using a mouse, keyboard and 10 key.
- Use of internet, familiarity with SharePoint sites.
- Ability to review and draft correspondence in email system and word processing systems.
- Ability to use software for data analysis, reporting and sharing of information to problem solve.
- Ability to create and manipulate spreadsheets (i.e., data entry and format cells).

Office Math Skills
- Ability to process numbers, which is an essential skill for any problem solving situation in a claims environment.
- Skills in the use of a calculator (using percentages, multiplication and division) to determine appropriate benefit payment.
- Ability to calculate the manual pricing of claims. Skills to verify accuracy with visual percentage calculations.

Read, Interpret and Apply Information
- Ability to research information using available resources.
- Read and comprehend the information to analyze and apply logical thinking in making sound decisions.
- Understand and apply general instructions to appropriately and accurately process claims.
- Capacity to follow step-by-step and general directions, remain detail oriented and verify data including HIPAA documentation.
- Ability to investigate and review claim from initial receipt.
- Ability to apply in-depth problem solving with more complex claims.
- Ability to read and interpret contracts for outpatient and inpatient claims.

Medical & Billing Terminology
- Understanding of medical terminology used in claims documentation.
- Working knowledge of Medicaid and Medicare benefits.
- Familiarity with claims medical coding.
- Knowledge of the different standard claims forms used for physician and hospital billing.
- Understand Coordination of Benefits (COB) and Long term care (LTC) processes.
- Knowledge of state and/or federal guidelines that apply to the Medicaid or Medicare benefits.

Claims System Familiarity
- Ability to use a claims adjudication system to process claims, such as Facets.
- Ability to access documentation through the use of an image repository-review system, such as Macess.
- Ability to apply multiple market information to correctly process claims.
- Ability to identify system issues to management for problem solving.

Behavioral Competencies

Strategic Leadership

Be Strategic
- Demonstrates understanding of the organization's mission and strategies.
- Works to clarify and understand the broader purpose and mission of own work.
- Integrates and balances big-picture concerns with day-to-day activities.
- Generates innovative ideas and solutions to problems.
- Identifies opportunities to increase efficiency, simplicity, and revenue.

Make Sound Decisions
- Approaches problems with curiosity and open-mindedness.
- Collects sufficient information to understand problems and issues.
- Analyzes problems and issues from different points of view.
- Applies accurate logic and common sense in making decisions.

People Leadership

Develop/Support Organizational Talent
- Relates to people in an open, friendly, and accepting manner.
- Treats others with respect.
- Listens carefully and attentively to others’ opinions and ideas.
- Maintains positive relationships even under difficult or heated circumstances.
- Works cooperatively with people from different cultural backgrounds.

Ensure Collaboration
- Encourages people to draw on each other's strengths and experience to work together effectively, within and across teams.
- Appropriately involves others in decisions and plans that affect them.
- Provides honest, helpful feedback to others on their performance.
- Shares own experience and expertise with others.

Results Leadership

Show Drive and Initiative
- Demonstrates a "can-do" spirit, a sense of optimism, ownership, and commitment.
- Maintains a consistent, high level of productivity.
- Takes personal responsibility to make decisions and take action.
- Does not easily give up in the face of unexpected obstacles.
- Projects a positive image and serves as a role model for others.

Accountability / Optimize Execution
- Juggles many priorities and competing demands for one's time.
- Acts resourcefully to ensure that work is completed within specified time and quality parameters.
- Removes obstacles in order to move the work forward and/or get efforts back on track.
- Surfaces problems and issues before projects get derailed.

PHYSICAL REQUIREMENTS

The physical requirements described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Must be able to operate general office equipment including but not limited to: computer, phones and related media and information devices.
- Ability to communicate both in person and/or by telephone.
- Must be able to travel as needed and adhere to Amerigroup travel policies and procedures.

ermCS
]]>Fri, 17 May 2013 00:00:00 GMThttp://www.amerigroup-jobs.com/job/Houston-Claims-Analyst-Job-TX-77001/2604267/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSShttp://www.amerigroup-jobs.com/job/Houston-Claims-Analyst-Job-TX-77001/2604267/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS
Job ID 2013-22140 # Positions 1
Location US-VA-Norfolk
Search Category Health Care Operations
Type Regular Full-Time (30+ hours) Posted Date 2/28/2013
Additional Locations ..

More information about this job:
Summary:

Responsible for reviewing medical records for claims submitted to Amerigroup which are potentially related to fraudulent or abusive billing practices. Work closely with all CID associates sharing knowledge, researching issues, documenting findings, drawing conclusions, and addressing issues with providers. Utilize a variety of resources to provide support for findings, keep informed of trends and changes in the medical field, and educate associates and providers. Work with Amerigroup Medical Directors to confirm findings, obtain guidance, and resolve issues relevant to CID investigations or department initiatives.

Responsibilities:

1. Performs all activities to identify, monitor and analyze aberrant patterns of utilization and/or fraudulent activities by health care providers through prepayment claims review and post payment auditing. Investigates potential fraud and over-utilization by performing complex medical reviews via prepayment claims review and post payment auditing.

2. Correlates review findings with appropriate actions (provider education, recovery of monies, cost avoidance, recommending sanctions or other actions).

3. Assists investigators by providing medical review expertise to accomplish the detection of fraudulent activities. Trains, educates, develops, and mentors other associates in the department.

4. Interfaces with operational department management, Health Plans and State representatives on fraud and abuse issues. Ensures continuing development of effective professional relationships with the Legal, Medical Management, Claims and Cost Containment Departments.

5. Assists in the development of departmental policies and procedures regarding documentation and coding standards. Develops appropriate process and case documentation to support the mission of the Corporate Investigations Department. 6. Establishes and maintains working relationships with all internal departments and senior management in the plan(s) to which they are assigned including CEO’s, Chief Compliance Officers, medical Directors, Provider Relations, Claims, etc.

7. Analyzes data as part of the investigative process using available resources.

8. Prepares and submits findings and makes recommendations to senior management.

9. Participates in identifying new initiatives and/or projects that will identify and reduce fraud and abuse, to include pre and post payment.

10. Assists in the evaluation and implementation of strategies to flag and evaluation claims of certain providers who are billing out of normal ranges, to include training the providers.

11. Assists in the evaluation, design and implementation of strategies to send communications to providers who are billing out of normal ranges, to include training the providers and monitoring impact on future billing patterns.

12. Develops, maintains and recommends current departmental coding resources.

13. Performs other duties as assigned or requested.

Qualifications:

EDUCATION REQUIREMENTS

Education

Bachelor’s degree in related field such as Nursing, Healthcare Management, or Health Information Systems. Equivalent work experience accepted in lieu of education.

Years and Type of Experience Required:

Required:
- Minimum 5 years claim coding experience with two years medical claims review and/or auditing experience.

Preferred:
- Minimum 5 years claim coding experience with two years medical claims review and/or auditing experience and minimum of two years of health care fraud audit/investigation experience in managed care setting is strongly preferred.
- Previous experience coordinating with internal legal representation.

Certifications or Licensures

Required:
- Certified Professional Coder (Requirement may vary by department).

Preferred:
- Registered Nurse or Licensed Practical Nurse (Requirement may vary by department).
- Certified Fraud Examiner (CFE).
- Accredited HealthCare Fraud Investigator (AHFI).

Language Skills

Required:
- English

Functional Competencies
- Demonstrated experience in Microsoft office products: Word, Excel and Power Point.
- Understanding of CMS 1500 and UB04 billing claim forms.
- Coding experience (ICD-9, CPT-4, E&M and HCPCS).
- Demonstrated experience with data mining, analysis, reporting and business intelligence techniques.
- Experience with healthcare claims systems (Facets and/or AMISYS).
- Experience with desktop coding platforms.
- Ability to provide testimony in civil or criminal hearings.

PHYSICAL REQUIREMENTS

The physical requirements described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Must be able to operate general office equipment including but not limited to: computer, phones and related media and information devices.
- Ability to communicate both in person and/or by telephone.
- Must be able to travel as needed (approximately 10%) and adhere to AMERIGROUP travel policies and procedures.

ermHO
]]>Sat, 27 Apr 2013 03:00:00 GMThttp://www.amerigroup-jobs.com/job/Norfolk-Clinical-Auditor-Reimbursement-Job-VA-23501/2455579/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSShttp://www.amerigroup-jobs.com/job/Norfolk-Clinical-Auditor-Reimbursement-Job-VA-23501/2455579/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS
Job ID 2013-22637 # Positions 1
Location US-NATIONWIDE
Search Category Finance
Type Regular Full-Time (30+ hours) Posted Date 4/19/2013
Additional Locations ..

More information about this job:
Summary:

The VP Finance (Plan) is responsible for owning, managing, and driving the budgeting, forecasting, and financial analysis functions of the health plan or region to ensure the achievement of membership, premium, medical expense, gross margin, and local SG&A goals on a quarterly and annual basis. Major activities owned by this position include the annual budget, quarterly forecasts, financial statement analysis and interpretation, ownership of the ACT process to maximize gross margin, and participation in the premium rate-setting process. The VP will work collaboratively with health plan and corporate management in all areas of responsibility to ensure the organization is focused on current results vs. budget, current financial performance trends, and the identification and execution of initiatives to properly manage revenue, medical, gross margin, and SG&A to plan.

Responsibilities:

1. Own topline, medical expense, and local/direct SG&A portions of annual budget process & quarterly forecasts:

a. Drive process with Plan leadership in conjunction with CEO/COO.

b. Conduct/coordinate all analysis required for membership, premium yield, medical expense, and local/direct admin by product.

c. Provide all required files to Home Office Finance departments within required timeframes.

2. Provide updated topline and medical projections as needed by the Home Office due to material changes in the business environment (new membership, new product, new provider contract, etc.)

3. On a monthly and quarterly basis, provide necessary information to Actuarial for the medical accruals including:

a. Large cases not in claim experience.

b. Major contract changes not in claim experience.

c. Other utilization or unit cost events not in claim experience.

4. Full participation in monthly operational meetings, financial statement meetings, and medical accrual meetings.

5. On a quarterly basis, provide all necessary information for the other known liabilities, including detailed analysis for auditor review, within required timelines of close process.

6. On a monthly basis, analyze, interpret, and communicate financial statement and medical accrual results to plan leadership for the month, quarter-to-date, and year-to-date:

a. Identify and explain all variances to budget/forecast.

b. Identify trends & key drivers in revenue and medical and roll them into ACT process for action.

c. Assess impact on quarterly and full year budget/forecast targets for topline, medical expenses, gross margin, HBR, and pre-tax/pre-corporate earnings.

7. Own the ACT program and ensure its success for the health plan in achieving revenue, medical, and gross margin targets on a quarterly and annual basis according to budget/forecast.

8. Conduct and manage all required analysis for the ACT program:

a. Identify, assess, document, and monitor all opportunities to maximize revenue and manage medical expenses to budget/forecast through membership, premium rate, unit cost, utilization, and cost containment initiatives.

b. Ensure 150% of gross margin gap to budget/forecast is explained at all times.

c. Fully utilize process tools and methodologies in accordance with Corporate standards.

9. Fully engage with other Plans and Home Office departments to identify, define, and use standard tools and analytical approaches, including use of common data sets. Interaction with Medical Finance, Finance, Medical Management, Claims, Cost Containment, Provider Service Operations, and Premium Reconciliation is expected.

10. Participate and contribute to “Best Practice” forums with other Plans and Home Office to share initiative successes, share lessoned learned, identify best practices across the company, and identify new initiatives not currently implemented at the Plan.

11. Monitor monthly cost containment activity, including investigation and resolution of adverse changes in collection activity a. Provide direction to Cost Containment Unit for additional expense savings opportunities not taken.

12. Monitor monthly claims production, including investigation and resolution of adverse changes in production statistics and their impact on medical accrual estimates.

13. Monitor monthly supplemental revenue collections such as Maternity kick payments, Newborn kick payment, and reimbursable drugs, including investigation and resolution of adverse changes in collection activity.

14. Monitor, analyze, and report any variances for local and direct administration expenses.

15. Identify and drive opportunities for savings with Plan leadership on a monthly basis.

16. Work with Actuarial to understand key drivers of the premium development for each product.

17. Identify and monitor the assumptions and issues in the rate methodology that drive financial success including trend, populations covered, benefits covered, unit cost assumptions, risk adjustment, birth rates, newborn enrollment rules, special populations (i.e. AIDS/HIV), utilization assumptions, and program changes.

a. Communicate to key Plan leadership and ensure they understand the drivers of success underneath the premium rates.

b. Monitor performance against quantifiable drivers of premium rates and resolve adverse variances as they arise.

Qualifications:

EDUCATION AND EXPERIENCE

Education

Required:
- MBA or CPA

Years and Type of Experience Required:

Required:
- 12+ years Managed Care Finance, Accounting, or Actuarial experience in a leadership role in a health plan and at least 5 years leadership management experience.

Specific Technical Skills

Required:
- Proficient in Microsoft Windows environment including the Office suite of products, proficiency with database programs such as Microsoft Access, advanced skills in Microsoft Excel, advanced analytical skills, and excellent communication skills.

Preferred:
- Hyperion Pillar, SPSS or equivalent, SQL

SCOPE INFORMATION

# Direct Reports:

# Indirect Reports:

Budgetary Responsibility: Entire Plan budget

PHYSICAL REQUIREMENTS
- Must be able to operate a computer.
- Must be able to operate a telephone.
- Travel required and must be able to travel on common carriers and to adhere to AMERIGROUP’s travel policies.
- Standing and sitting for long periods of time.
- Data Entry using repetitive motions of fingers and forearms.

ermCorp
]]>Sat, 18 May 2013 05:31:00 GMThttp://www.amerigroup-jobs.com/job/Vice-President-Finance-Position-located-in-Kansas-Job/2556788/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSShttp://www.amerigroup-jobs.com/job/Vice-President-Finance-Position-located-in-Kansas-Job/2556788/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS
Job ID 2013-22737 # Positions 1
Location US-CA-Thousand Oaks
Search Category Health Care Operations
Type Regular Full-Time (30+ hours) Posted Date 5/6/2013
Additional Locations ..

More information about this job:
Summary:

The VP Finance (Plan) will largely focus and be accountable for identifying and valuing solutions which serve to improve the operating performance of the Plan through strategies and initiatives which contribute to effectively managing operating gain. This includes a focus on topline, capital investments in the local operations, management of local administrative costs, and driving medical expense improvements. This position is responsible for owning, managing, and driving the budgeting, forecasting, and financial analysis functions of the health plan or region to ensure the achievement of membership, premium, medical expense, gross margin, and local SG&A goals on a quarterly and annual basis, plus local analytics and reporting necessary to support business decisions across all functional areas with actionable information. Major activities owned by this position include the annual budget, quarterly forecasts, financial statement analysis and interpretation, ownership of the HCI/CoC process to maximize operating gain, management and tracking of the State P4P incentive programs and process, and participation in the premium rate-setting process. The VP will work collaboratively with health plan and corporate management in all areas of responsibility to ensure the organization is focused on current results vs. budget, current financial performance trends, and the identification and execution of initiatives to properly manage revenue, medical, gross margin, and SG&A to plan. The incumbent will be responsible for partnering with the QM lead to drive the P4P/HEDIS management and the oversight process for analytics and reporting. This position will also focus and be accountable for identifying and valuing solutions which serve to improve the operating performance of the Plan through strategies and initiatives which contribute to effectively managing the medcial expense (MLR).

Responsibilities:

1. Own topline, medical expense, and local/direct SG&A portions of annual budget process & quarterly forecasts:

a. Drive process with Plan leadership in conjunction with CEO/COO;

b. Conduct/coordinate all analysis required for membership, premium yield, medical expense, quality initiatives, incentive programs, and local/direct admin by product;

c. Provide all required files to Home Office Finance departments within required timeframes.

2. Provide updated topline and medical projections as needed by the Home Office due to material changes in the business environment (new membership, new product, new provider contract, etc.)

3. On a monthly and quarterly basis, provide necessary information to Actuarial for the medical accruals including:

a. Large cases not in claim experience;

b. Major contract changes not in claim experience;

c. Other utilization or unit cost events not in claim experience.

4. Full participation in monthly operational meetings, financial statement meetings, and medical accrual meetings.

5. On a quarterly basis, provide all necessary information for the other known liabilities, including detailed analysis for auditor review, within required timelines of close process.

6. On a monthly basis, analyze, interpret, and communicate financial statement and medical accrual results to plan leadership for the month, quarter-to-date, and year-to-date a. Identify and explain all variances to budget/forecast b. Identify trends & key drivers in revenue and medical and roll them into HCI process for action c. Assess impact on quarterly and full year budget/forecast targets for topline, medical expenses, gross margin, MLR, pre-tax/pre-corporate earnings, and operating gain.

7. Own the HCI program and ensure its success for the health plan in achieving revenue, medical, and gross margin targets on a quarterly and annual basis according to budget/forecast.

8. Conduct and manage all required analysis for the HCI program:

a. Identify, assess, document, and monitor all opportunities to maximize revenue and manage medical expenses to budget/forecast through membership, premium rate, unit cost, utilization, and cost containment initiatives;

b. Ensure 150% of gross margin gap to budget/forecast is explained at all times;

c. Fully utilize process tools and methodologies in accordance with Corporate standards.

9. Fully engage and collaborate with other Plans and Home Office departments to identify, define, and use standard tools and analytical approaches, including use of common data sets. Interaction with Health Care Economics, Finance, Medical Management, Claims, Cost Containment, Provider Service Operations, Program Integrity, and Premium Reconciliation is expected.

10. Participate and contribute to “Best Practice” forums with other Plans and Home Office to share initiative successes, share lessoned learned, identify best practices across the company, and identify new initiatives not currently implemented at the Plan.

11. Monitor monthly cost containment activity, including investigation and resolution of adverse changes in collection activity a. Provide direction to Cost Containment Unit for additional expense savings opportunities not taken.

12. Monitor monthly claims production, including investigation and resolution of adverse changes in production statistics and their impact on medical accrual estimates.

13. Monitor monthly supplemental revenue collections such as Maternity kick payments, Newborn kick payment, and reimbursable drugs, including investigation and resolution of adverse changes in collection activity.

14. Monitor, analyze, and report any variances for local and direct administration expenses.

15. Identify and drive opportunities for savings with Plan leadership on a monthly basis.

16. Work with Actuarial to understand key drivers of the premium development for each product.

17. Identify and monitor the assumptions and issues in the rate methodology that drive financial success including trend, populations covered, benefits covered, unit cost assumptions, risk adjustment, birth rates, newborn enrollment rules, special populations (i.e. AIDS/HIV), utilization assumptions, and program changes.

a. Communicate to key Plan leadership and ensure they understand the drivers of success underneath the premium rates;

b. Monitor performance against quantifiable drivers of premium rates and resolve adverse variances as they arise.

18. Partner with Quality Management Leadership to own and drive any State required P4P incentive programs and HEDIS improvements. Own scorecard development and tracking, sizing of risks and opportunities with achieving premium incentive goals, identify and monitor compliance risks and financial impacts, and provide routine analysis and reporting to QM team to ensure successful initiatives and outcomes:

a. Provide financial and analytical oversight in development of member and provider incentive programs;

b. Provide outcomes reporting and assessment of quality initiatives.

19. Manage all analytics and reporting at the Plan level.

Qualifications:

EDUCATION AND EXPERIENCE

Education

Required:
- MBA or CPA

Years and Type of Experience Required:

Required:
- 12 years Managed Care Finance, Accounting, or Actuarial experience in a leadership role in a health plan and at least 5 years leadership management experience Specific Technical Skills

Required:
- Proficient in Microsoft Windows environment including the Office suite of products, proficiency with database programs such as Microsoft Access, advanced skills in Microsoft Excel, advanced analytical skills, and excellent communication skills.

SCOPE INFORMATION

# Direct Reports:

# Indirect Reports:

Budgetary $ Responsibility: Entire Plan budget

PHYSICAL REQUIREMENTS

The physical requirements described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Must be able to operate general office equipment including but not limited to: computer, phones and related media and information devices.
- Ability to communicate both in person and/or by telephone.
- Must be able to travel as needed and adhere to Amerigroup travel policies and procedures.

Job Title: VP Finance

Job Grade: 23

Salary Range: S107,021 - $142,695 - $178,369

MJO: 20%

LTI: 15k

ermHO
]]>Mon, 06 May 2013 00:00:00 GMThttp://www.amerigroup-jobs.com/job/Thousand-Oaks-VP-Finance-Plan-Job-CA-91319/2582913/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSShttp://www.amerigroup-jobs.com/job/Thousand-Oaks-VP-Finance-Plan-Job-CA-91319/2582913/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS
Job ID 2013-22736 # Positions 1
Location US-IN-Indianapolis
Search Category Health Care Operations
Type Regular Full-Time (30+ hours) Posted Date 5/10/2013
Additional Locations ..

More information about this job:
Summary:

The VP Finance (Plan) will largely focus and be accountable for identifying and valuing solutions which serve to improve the operating performance of the Plan through strategies and initiatives which contribute to effectively managing operating gain. This includes a focus on topline, capital investments in the local operations, management of local administrative costs, and driving medical expense improvements. This position is responsible for owning, managing, and driving the budgeting, forecasting, and financial analysis functions of the health plan or region to ensure the achievement of membership, premium, medical expense, gross margin, and local SG&A goals on a quarterly and annual basis, plus local analytics and reporting necessary to support business decisions across all functional areas with actionable information. Major activities owned by this position include the annual budget, quarterly forecasts, financial statement analysis and interpretation, ownership of the HCI/CoC process to maximize operating gain, management and tracking of the State P4P incentive programs and process, and participation in the premium rate-setting process. The VP will work collaboratively with health plan and corporate management in all areas of responsibility to ensure the organization is focused on current results vs. budget, current financial performance trends, and the identification and execution of initiatives to properly manage revenue, medical, gross margin, and SG&A to plan. The incumbent will be responsible for partnering with the QM lead to drive the P4P/HEDIS management and the oversight process for analytics and reporting.

Responsibilities:

1. Own topline, medical expense, and local/direct SG&A portions of annual budget process & quarterly forecasts:

a. Drive process with Plan leadership in conjunction with CEO/COO;

b. Conduct/coordinate all analysis required for membership, premium yield, medical expense, quality initiatives, incentive programs, and local/direct admin by product;

c. Provide all required files to Home Office Finance departments within required timeframes.

2. Provide updated topline and medical projections as needed by the Home Office due to material changes in the business environment (new membership, new product, new provider contract, etc.)

3. On a monthly and quarterly basis, provide necessary information to Actuarial for the medical accruals including:

a. Large cases not in claim experience;

b. Major contract changes not in claim experience;

c. Other utilization or unit cost events not in claim experience.

4. Full participation in monthly operational meetings, financial statement meetings, and medical accrual meetings.

5. On a quarterly basis, provide all necessary information for the other known liabilities, including detailed analysis for auditor review, within required timelines of close process.

6. On a monthly basis, analyze, interpret, and communicate financial statement and medical accrual results to plan leadership for the month, quarter-to-date, and year-to-date a. Identify and explain all variances to budget/forecast b. Identify trends & key drivers in revenue and medical and roll them into HCI process for action c. Assess impact on quarterly and full year budget/forecast targets for topline, medical expenses, gross margin, MLR, pre-tax/pre-corporate earnings, and operating gain.

7. Own the HCI program and ensure its success for the health plan in achieving revenue, medical, and gross margin targets on a quarterly and annual basis according to budget/forecast.

8. Conduct and manage all required analysis for the HCI program:

a. Identify, assess, document, and monitor all opportunities to maximize revenue and manage medical expenses to budget/forecast through membership, premium rate, unit cost, utilization, and cost containment initiatives;

b. Ensure 150% of gross margin gap to budget/forecast is explained at all times;

c. Fully utilize process tools and methodologies in accordance with Corporate standards.

9. Fully engage and collaborate with other Plans and Home Office departments to identify, define, and use standard tools and analytical approaches, including use of common data sets. Interaction with Health Care Economics, Finance, Medical Management, Claims, Cost Containment, Provider Service Operations, Program Integrity, and Premium Reconciliation is expected.

10. Participate and contribute to “Best Practice” forums with other Plans and Home Office to share initiative successes, share lessoned learned, identify best practices across the company, and identify new initiatives not currently implemented at the Plan.

11. Monitor monthly cost containment activity, including investigation and resolution of adverse changes in collection activity a. Provide direction to Cost Containment Unit for additional expense savings opportunities not taken.

12. Monitor monthly claims production, including investigation and resolution of adverse changes in production statistics and their impact on medical accrual estimates.

13. Monitor monthly supplemental revenue collections such as Maternity kick payments, Newborn kick payment, and reimbursable drugs, including investigation and resolution of adverse changes in collection activity.

14. Monitor, analyze, and report any variances for local and direct administration expenses.

15. Identify and drive opportunities for savings with Plan leadership on a monthly basis.

16. Work with Actuarial to understand key drivers of the premium development for each product.

17. Identify and monitor the assumptions and issues in the rate methodology that drive financial success including trend, populations covered, benefits covered, unit cost assumptions, risk adjustment, birth rates, newborn enrollment rules, special populations (i.e. AIDS/HIV), utilization assumptions, and program changes.

a. Communicate to key Plan leadership and ensure they understand the drivers of success underneath the premium rates;

b. Monitor performance against quantifiable drivers of premium rates and resolve adverse variances as they arise.

18. Partner with Quality Management Leadership to own and drive any State required P4P incentive programs and HEDIS improvements. Own scorecard development and tracking, sizing of risks and opportunities with achieving premium incentive goals, identify and monitor compliance risks and financial impacts, and provide routine analysis and reporting to QM team to ensure successful initiatives and outcomes:

a. Provide financial and analytical oversight in development of member and provider incentive programs;

b. Provide outcomes reporting and assessment of quality initiatives.

19. Manage all analytics and reporting at the Plan level.

Qualifications:

EDUCATION AND EXPERIENCE

Education

Required:
- MBA or CPA

Years and Type of Experience Required:

Required:
- 12 years Managed Care Finance, Accounting, or Actuarial experience in a leadership role in a health plan and at least 5 years leadership management experience Specific Technical Skills

Required:
- Proficient in Microsoft Windows environment including the Office suite of products, proficiency with database programs such as Microsoft Access, advanced skills in Microsoft Excel, advanced analytical skills, and excellent communication skills.

SCOPE INFORMATION

# Direct Reports:

# Indirect Reports:

Budgetary $ Responsibility: Entire Plan budget

PHYSICAL REQUIREMENTS

The physical requirements described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Must be able to operate general office equipment including but not limited to: computer, phones and related media and information devices.
- Ability to communicate both in person and/or by telephone.
- Must be able to travel as needed and adhere to Amerigroup travel policies and procedures.

Job Title: VP Finance

Job Grade: 23

Salary Range: $101,925 - $135,900 - $169,875

MJO:20%

LTI:15k

ermHO
]]>Fri, 10 May 2013 00:00:00 GMThttp://www.amerigroup-jobs.com/job/Indianapolis-VP-Finance-Plan-Job-IN-46201/2592123/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSShttp://www.amerigroup-jobs.com/job/Indianapolis-VP-Finance-Plan-Job-IN-46201/2592123/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS
Job ID 2013-22735 # Positions 1
Location US-VA-Richmond
Search Category Health Care Operations
Type Regular Full-Time (30+ hours) Posted Date 5/10/2013
Additional Locations ..

More information about this job:
Summary:

The VP Finance (Plan) will largely focus and be accountable for identifying and valuing solutions which serve to improve the operating performance of the Plan through strategies and initiatives which contribute to effectively managing operating gain. This includes a focus on topline, capital investments in the local operations, management of local administrative costs, and driving medical expense improvements. This position is responsible for owning, managing, and driving the budgeting, forecasting, and financial analysis functions of the health plan or region to ensure the achievement of membership, premium, medical expense, gross margin, and local SG&A goals on a quarterly and annual basis, plus local analytics and reporting necessary to support business decisions across all functional areas with actionable information. Major activities owned by this position include the annual budget, quarterly forecasts, financial statement analysis and interpretation, ownership of the HCI/CoC process to maximize operating gain, management and tracking of the State P4P incentive programs and process, and participation in the premium rate-setting process. The VP will work collaboratively with health plan and corporate management in all areas of responsibility to ensure the organization is focused on current results vs. budget, current financial performance trends, and the identification and execution of initiatives to properly manage revenue, medical, gross margin, and SG&A to plan. The incumbent will be responsible for partnering with the QM lead to drive the P4P/HEDIS management and the oversight process for analytics and reporting.

Responsibilities:

1. Own topline, medical expense, and local/direct SG&A portions of annual budget process & quarterly forecasts:

a. Drive process with Plan leadership in conjunction with CEO/COO;

b. Conduct/coordinate all analysis required for membership, premium yield, medical expense, quality initiatives, incentive programs, and local/direct admin by product;

c. Provide all required files to Home Office Finance departments within required timeframes.

2. Provide updated topline and medical projections as needed by the Home Office due to material changes in the business environment (new membership, new product, new provider contract, etc.)

3. On a monthly and quarterly basis, provide necessary information to Actuarial for the medical accruals including:

a. Large cases not in claim experience;

b. Major contract changes not in claim experience;

c. Other utilization or unit cost events not in claim experience.

4. Full participation in monthly operational meetings, financial statement meetings, and medical accrual meetings.

5. On a quarterly basis, provide all necessary information for the other known liabilities, including detailed analysis for auditor review, within required timelines of close process.

6. On a monthly basis, analyze, interpret, and communicate financial statement and medical accrual results to plan leadership for the month, quarter-to-date, and year-to-date a. Identify and explain all variances to budget/forecast b. Identify trends & key drivers in revenue and medical and roll them into HCI process for action c. Assess impact on quarterly and full year budget/forecast targets for topline, medical expenses, gross margin, MLR, pre-tax/pre-corporate earnings, and operating gain.

7. Own the HCI program and ensure its success for the health plan in achieving revenue, medical, and gross margin targets on a quarterly and annual basis according to budget/forecast.

8. Conduct and manage all required analysis for the HCI program:

a. Identify, assess, document, and monitor all opportunities to maximize revenue and manage medical expenses to budget/forecast through membership, premium rate, unit cost, utilization, and cost containment initiatives;

b. Ensure 150% of gross margin gap to budget/forecast is explained at all times;

c. Fully utilize process tools and methodologies in accordance with Corporate standards.

9. Fully engage and collaborate with other Plans and Home Office departments to identify, define, and use standard tools and analytical approaches, including use of common data sets. Interaction with Health Care Economics, Finance, Medical Management, Claims, Cost Containment, Provider Service Operations, Program Integrity, and Premium Reconciliation is expected.

10. Participate and contribute to “Best Practice” forums with other Plans and Home Office to share initiative successes, share lessoned learned, identify best practices across the company, and identify new initiatives not currently implemented at the Plan.

11. Monitor monthly cost containment activity, including investigation and resolution of adverse changes in collection activity a. Provide direction to Cost Containment Unit for additional expense savings opportunities not taken.

12. Monitor monthly claims production, including investigation and resolution of adverse changes in production statistics and their impact on medical accrual estimates.

13. Monitor monthly supplemental revenue collections such as Maternity kick payments, Newborn kick payment, and reimbursable drugs, including investigation and resolution of adverse changes in collection activity.

14. Monitor, analyze, and report any variances for local and direct administration expenses.

15. Identify and drive opportunities for savings with Plan leadership on a monthly basis.

16. Work with Actuarial to understand key drivers of the premium development for each product.

17. Identify and monitor the assumptions and issues in the rate methodology that drive financial success including trend, populations covered, benefits covered, unit cost assumptions, risk adjustment, birth rates, newborn enrollment rules, special populations (i.e. AIDS/HIV), utilization assumptions, and program changes.

a. Communicate to key Plan leadership and ensure they understand the drivers of success underneath the premium rates;

b. Monitor performance against quantifiable drivers of premium rates and resolve adverse variances as they arise.

18. Partner with Quality Management Leadership to own and drive any State required P4P incentive programs and HEDIS improvements. Own scorecard development and tracking, sizing of risks and opportunities with achieving premium incentive goals, identify and monitor compliance risks and financial impacts, and provide routine analysis and reporting to QM team to ensure successful initiatives and outcomes:

a. Provide financial and analytical oversight in development of member and provider incentive programs;

b. Provide outcomes reporting and assessment of quality initiatives.

19. Manage all analytics and reporting at the Plan level.

Qualifications:

EDUCATION AND EXPERIENCE

Education

Required:
- MBA or CPA

Years and Type of Experience Required:

Required:
- 12 years Managed Care Finance, Accounting, or Actuarial experience in a leadership role in a health plan and at least 5 years leadership management experience Specific Technical Skills

Required:
- Proficient in Microsoft Windows environment including the Office suite of products, proficiency with database programs such as Microsoft Access, advanced skills in Microsoft Excel, advanced analytical skills, and excellent communication skills.

SCOPE INFORMATION

# Direct Reports:

# Indirect Reports:

Budgetary $ Responsibility: Entire Plan budget

PHYSICAL REQUIREMENTS

The physical requirements described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Must be able to operate general office equipment including but not limited to: computer, phones and related media and information devices.
- Ability to communicate both in person and/or by telephone.
- Must be able to travel as needed and adhere to Amerigroup travel policies and procedures.

Job Title: VP Finance

Job Grade: 23

Salary Range: $101,925 - $135,900 - $169,875

MJO:20%

LTI:15k

ermHO
]]>Fri, 10 May 2013 00:00:00 GMThttp://www.amerigroup-jobs.com/job/Richmond-VP-Finance-Plan-Job-VA-23173/2592124/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSShttp://www.amerigroup-jobs.com/job/Richmond-VP-Finance-Plan-Job-VA-23173/2592124/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS
Job ID 2013-22820 # Positions 1
Location US-VA-Virginia Beach
Search Category Customer Service
Type Regular Full-Time (30+ hours) Posted Date 5/10/2013
Additional Locations ..

More information about this job:
Summary:

Provides leadership and direction for all production-related cost containment activities across all markets to include overpayment recovery, coordination of benefits, third party liability recovery, fraud and abuse and medical claims review. Accountable for team performance measures. Manages cost containment vendor relationships. Serves as a primary contact for legal and regulatory issues regarding claims or cost containment. Possesses the business and technical expertise required to perform the critical tasks of the job.

Responsibilities:

1. Ensure recovery PMPM and overall dollar targets are met.

2. Coordinate efforts with health plans to maximize recovery efforts, yet minimize impact to provider networks.

3. Establish/maintain/improve processes to identify and recover overpaid/misplaced funds while ensuring adherence to state mandated requirements.

4. Coordinate closely with Legal and Provider Configuration to “flag” suspect providers, conduct investigations and close cases in a timely manner.

5. Coordinate with Claims teams to help identify potential recovery opportunities and to communicate any root causes of errors found in the overpayment review process.

6. Implement quality assurance program across all functions within Cost Containment.

7. Coordinate with Quality Assurance and cost containment vendors to track processing errors seen in overpayment recovery. Provide feedback to appropriate department such as Claims, Enrollment and Provider Configuration.

8. Partner with Medical Finance to ensure reported savings are accurate and validated.

9. Ensure that information provided to Cost Containment team members is consistent with information other departments, i.e., Special Processing Instructions (SPIs) from Claims, Medical Management information, etc.

10. Responsible for writing and updating policies and procedures related to cost containment activities.

11. Performs other duties as assigned.

Qualifications:

EDUCATION AND EXPERIENCE

Education

Required:
- Bachelor’s degree in related field or equivalent experience.

Years and Type of Experience Required:

Required:
- Five years of experience in operations in a managed care or financial organization with at least one year of leadership/supervisory experience.

Preferred:
- Cost containment or claims processing experience.

Language Skills

Required:
- English

Technical Competencies Computer Skills and Office Equipment
- Ability to use software and hardware of a computer to complete certain moderately-complex to complex tasks.
- Able to use basic office equipment such as telephone, fax machine and copy machine.
- Working knowledge in a windows environment to include navigation skills using a mouse, keyboard, 10 key and typing at 35 words/minute.
- Use of internet and some familiarity with SharePoint sites.
- Ability to review and draft correspondence in email system and word processing systems.
- Ability to use software for data analysis, reporting and sharing of information to problem solve.
- Ability to create and manipulate spreadsheets (i.e., data entry and format cells). - Ability to work in databases.

Read, Interpret and Apply Information
- Ability to research information using available resources.
- Read and comprehend the information to analyze and apply logical thinking in making sound decisions.
- Understand and apply general instructions to appropriately and accurately process claims.
- Capacity to follow step-by-step and general directions, remain detail oriented and verify data from EOB's including HIPAA documentation.
- Ability to investigate and review claim from initial receipt.
- Ability to apply in-depth problem solving with more complex claims.
- Ability to read and interpret contract terms as related to payment policies for outpatient and inpatient claims.

Medical, Recovery & Billing Terminology
- Understanding of medical terminology used in claims documentation.
- Knowledge of other healthcare companies and third party insurance.
- Understanding of Cost Containment/Overpayment processes, such as COB.
- Familiarity with claims medical coding.
- Working knowledge of recovery practices.
- Understand DRG, capitation - per diem rules.
- Understand the different levels of care and applicable payment methodology.

System Familiarity
- Ability to use a claims adjudication system to process claims, such as Facets.
- Familiarity with an image repository-review system for the retrieval of documents.
- Ability to identify system issues to management for problem solving.
- Understanding of the system configuration concepts for benefits, pricing, and provider set up.

Communication Skills: Verbal, Written and Telephonic
- Ability to convey complex messages to a variety of audiences in an effective manner using proper language, grammar and style in the preparation of verbal and written messages.
- Skills to properly handle telephone inquiry with customers (providers, vendors and other health insurance carriers).
- Ability to prepare, edit and convey a variety of messages including presentations, settlement materials and updates.
- Ability to handle escalated issues through verbal and written messages.

Behavioral Competencies

Strategic Leadership

Be Strategic
- Demonstrates understanding of the organization's mission and strategies.
- Sees the "big picture" (e.g., overall themes, trends, goals).
- Integrates and balances big-picture concerns with day-to-day activities.
- Establishes strategies for achieving individual or work unit goals.

Make Sound Decisions
- Analyzes, incorporates and applies new information and concepts.
- Recognizes symptoms that indicate problems.
- Makes sound decisions on everyday issues and problems.
- Makes timely decisions on problems/issues requiring immediate attention.

People Leadership Develop/Support Organizational Talent
- Identifies and recruits/refers qualified people.
- Makes accurate evaluations of people's capabilities and fit.
- Provides honest, helpful feedback to others on their performance.
- Shares own experience and expertise with others.

Ensure Collaboration
- Provides sound rationale for recommendations.
- Solicits support for ideas.
- Ensures that own positions address others' needs and priorities.
- Builds relationships to create a foundation for future influence.

Results Leadership Show Drive and Initiative
- Identifies what needs to be done and does it.
- Maintains a consistent, high level of productivity.
- Takes personal responsibility to make decisions and take action.
- Does not easily give up in the face of unexpected obstacles.

Accountability / Optimize Execution
- Juggles many priorities and competing demands for one's time.
- Conveys clear expectations for assignments.
- Removes obstacles in order to move the work forward and/or get efforts back on track.
- Seeks additional resources to complete tasks when needed.

SCOPE INFORMATION

# Direct Reports: 3-6

# Indirect Reports: 10-25

Budgetary $ Responsibility:

PHYSICAL REQUIREMENTS

The physical requirements described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Must be able to operate general office equipment including but not limited to: computer, phones and related media and information devices.
- Ability to communicate both in person and/or by telephone.
- Must be able to travel as needed and adhere to Amerigroup travel policies and procedures.

ermCS
]]>Fri, 10 May 2013 00:00:00 GMThttp://www.amerigroup-jobs.com/job/Virginia-Beach-Mgr-Cost-Containment-Job-VA-23450/2592121/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSShttp://www.amerigroup-jobs.com/job/Virginia-Beach-Mgr-Cost-Containment-Job-VA-23450/2592121/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS
Job ID 2013-22540 # Positions 1
Location US-VA-Virginia Beach
Search Category Human Resources
Type Regular Full-Time (30+ hours) Posted Date 4/10/2013
Additional Locations ..

More information about this job:
Summary:

Provide strategic, consultative Human Resource support and leadership for assigned business unit. Identify and frame human resource issues and solutions to business problems by providing human resource expertise in implementing the strategic business direction and in determining the essential tactical human resources elements.

Responsibilities:

1. Work closely with assigned business unit leaders to define and align HR strategy with business unit strategy. Partner with assigned client groups to gain understanding of client’s business in order to effectively support, propose and lead initiatives.

2. Act as advisor and coach on human resources issues such as associate issues and questions, managing change and supporting a positive work environment.

3. Conduct timely investigations into complaints of ADA, EEO, Workplace Harassment and other associate concerns. Provide oversight and guidance to HR generalists on sensitive associate issues.

4. Actively contribute to assembly and operation of a strong, diverse and client-focused HR team through effective recruiting, training, coaching and team building. Participate in the preparation of staff development plans. Select, develop and evaluate staff to ensure the efficient operation of the function. Provide leadership and direction to department staff as appropriate to ensure the quality of departmental work outcomes and deliverables.

5. Monitor industry and marketplace developments and trends and recommends changes and/or exceptions to established company policy and guidelines as necessary to ensure the efficient operation of the business. Work independently and in concert with other HR leaders to ensure the consistent interpretation and execution of Policy and Practices at all levels of the organization.

6. Partner with assigned business unit to support associate development and establish development plans, career paths and retention programs. Assess and make recommendations for organizational structure based on talent and organizational goals.

7. Design and implement strategies to support the business goals and culture through initiatives in diversity and leadership development including training, performance management and succession planning.

8. Actively contribute to assembly and operation of a strong, diverse and client-focused HR team through effective recruiting, training, coaching and team building. Participate in the preparation of staff development plans.

9. Lead/participate in a variety of projects and assignments including the development of personnel policies, procedures and programs.

10. Provide analysis, review and recommendations with regards to performance reviews, compensation changes/adjustments, merit increases and promotional increases for consistency and compliance with company policy and legal considerations.

11. Consult with assigned business unit leaders on the development and execution of staffing plans and job evaluations. Consult with business owners on the development and execution of departmental and business unit reorganization plans, reduction in force, and other resource re-deployment activities.

12. May plan and recommend budgets, manage expenditures, and report on budget variances.

13. May manage other areas such as Facilities, Security, Safety, Purchasing, or Training as assigned.

14. Other duties as assigned.

Qualifications:

Education

Required: Bachelor’s degree in related field or equivalent work experience.

Preferred: Master’s degree

Years and Type of Experience Required:

Required: Minimum 7 years of related work experience with at least 3 years of leadership/management experience.

Specific Technical Skills

Required: Excellent computer skills including Microsoft Office Suite

Preferred: Experience working with PeopleSoft

Certifications or Licensures

Preferred: SPHR

Other:

Required:
- Strong Employee Relations background and knowledge to include: federal, state and local laws and regulations including but not limited to: OFCCP, DOL, NLRA, FLSA, EEO, FMLA, ERISA laws/issues, etc.
- Comprehensive knowledge and experience in all areas of HR to include employment, compensation, benefits, employee relations, HRIS and payroll administration
- Ability to assess and develop solutions for organizational development and training needs.
- Experience in budgeting and strategic planning.
- Excellent verbal and written communication skills, especially giving and receiving feedback.
- Strong organizational and analytical skills.
- Provide high level of customer service.
- Strong interpersonal skills and ability to use tact and diplomacy.
- Ability to maintain confidentiality.
- Strong presentation skills.
- Dedicated team player, who demonstrates initiative and independence.
- Proven problem solving and negotiation skills.
- Must be flexible; able to handle multiple projects and changing priorities.
- High energy and a positive can-do attitude.
- Motivates others, provides innovative ideas and solutions, and promotes the department vision for improvement.
- Previous experience in working within a highly-matrixed environment. Ability to deliver by managing through others.
- Ability to perform in a fast paced environment and make appropriate decisions quickly.
- Excellent negotiation skills and proven management skills.
- Appreciation of cultural diversity and sensitivity towards target population.

SCOPE INFORMATION
- # Direct Reports: 1-4
- # Indirect Reports:

Varies Budgetary $ Responsibility:

Varies based on assignment

PHYSICAL REQUIREMENTS: The physical requirements described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Must be able to operate general office equipment including but not limited to: computer, phones and related media and information devices.
- Ability to communicate both in person and/or by telephone.
- Must be able to travel as needed and adhere to AMERIGROUP travel policies and procedures

ermCorp
]]>Thu, 09 May 2013 02:59:00 GMThttp://www.amerigroup-jobs.com/job/Virginia-Beach-Director-Human-Resources-Job-VA-23450/2540206/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSShttp://www.amerigroup-jobs.com/job/Virginia-Beach-Director-Human-Resources-Job-VA-23450/2540206/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS
Job ID 2013-21589 # Positions 1
Location US-VA-Norfolk
US-VA-Richmond
Search Category Health Care Operations
Type Regular Full-Time (30+ hours) Posted Date 1/7/2013
Additional Locations US-VA-Richmond

More information about this job:
Summary:

Develop, implement and manage both corporate initiated and health plan initiated programs targeted at wellness, early intervention, education and member/provider communications. Provide oversight,coordination and collaboration across health plans and corporate departments. Ensures that all health education materials meet best clinical practice guidelines and are in compliance with Amerigroup Clinical Practice Guidelines (CPGs), policies and regulatory requirements.

Responsibilities:

1. Develop strategies and programs to promote a culture of health and healthly lifestype behaviors. Investigates and recommends management strategies that can enhance Amerigroup’s ability to provide members and providers with cutting edge services and programs.

2. Oversee the tracking and timeliness of all deliverables, to include appropriate quality metrics and IT support systems to ensure appropriate resources are in place to support the workflow and volume.

3. Coordinate National Health Promotion initiatives that meet state regulatory, accreditation, HEDIS and clinical needs.

4. Coordinate all appropriate initiatives with the Behavioral Health clinical staff to ensure broad communication and validation is achieved.

5. Evaluate strategies for ongoing efficiency, effectiveness and appropriateness. Works with health plans to evaluate effectiveness of the program and to implement changes based on evaluation outcomes.

6. Work with IS and QM departments assisting in the development and implementation of survey instruments, data collection tools and reports related to the needs of the member/provider.

7. Provide input to senior management regarding program needs and new areas for program services development. Identify and recommend activities/services that promote member compliance/participation and retention.

8. Prepares summaries of activities and services, accomplishment reports, department updates and submits required reports to QM or other departments as directed. Create outcome focused management reports based on the identified business plan goals and objectives.

9. Assist with orientation and training of volunteers and students involved in prevention, education and outreach activities and events.

10. Participate in budget planning for the department and maintains expenses within the budget. Ensure’s expenditures are made in accordance with applicable policies and procedures.

11. Coach and develop team members; establish goals, performance standards and operating procedures. Act as an advisor to less experience staff.

12. Perform other duties as assigned.

Qualifications:

EDUCATION AND EXPERIENCE

Education

Required:
- Bachelor’s degree in Computer Science or related field. Equivalent experience is acceptable in lieu of a degree(s).

Years and Type of Experience Required:

Required:
- Entry level position for associates who have had sufficient educational background and/or experience to qualify them to start in applications systems analysis.

Language Skills

Required:
- English

Technical Competencies

Computer Hardware, Software and Applications / Office Equipment – Basic
- Basic understanding of core IT applications and systems and infrastructure associated with supported applications.
- Ability to use hardware and software of a computer to complete certain simple tasks. Skills to use basic office equipment such as telephone, fax machine and copy machine.
- Proficiency in a windows environment to include navigation skills and use of internet. Ability to review and draft correspondence in email and word processing systems. Ability to use spreadsheets to review, organize and edit data.

Applications System Analysis - Basic
- Basic understanding of coding standards. Basic understanding of object oriented development language, object state and methods, and encapsulation. Basic understanding of variables, data types, expressions, control flow statements, arrays and strings. Understands data modeling concepts and their application including entities, tables, relations, constraints, attribute data types and column data types.

Project Management - Basic
- Basic understanding of project management concepts.

Behavioral Competencies

Strategic Leadership

Be Strategic
- Demonstrates understanding of the organization's mission and strategies.
- Works to clarify and understand the broader purpose and mission of own work.
- Integrates and balances big-picture concerns with day-to-day activities.
- Generates innovative ideas and solutions to problems.
- Identifies opportunities to increase efficiency, simplicity, and revenue.

Make Sound Decisions
- Approaches problems with curiosity and open-mindedness.
- Collects sufficient information to understand problems and issues.
- Analyzes problems and issues from different points of view.
- Applies accurate logic and common sense in making decisions.

People Leadership

Develop/Support Organizational Talent
- Relates to people in an open, friendly, and accepting manner.
- Treats others with respect.
- Listens carefully and attentively to others’ opinions and ideas.
- Maintains positive relationships even under difficult or heated circumstances.
- Works cooperatively with people from different cultural backgrounds.

Ensure Collaboration
- Encourages people to draw on each other's strengths and experience to work together effectively, within and across teams.
- Appropriately involves others in decisions and plans that affect them.
- Provides honest, helpful feedback to others on their performance.
- Shares own experience and expertise with others.

Results Leadership

Show Drive and Initiative
- Demonstrates a "can-do" spirit, a sense of optimism, ownership, and commitment.
- Maintains a consistent, high level of productivity.
- Takes personal responsibility to make decisions and take action.
- Does not easily give up in the face of unexpected obstacles.
- Projects a positive image and serves as a role model for others.

Accountability / Optimize Execution
- Juggles many priorities and competing demands for one's time.
- Acts resourcefully to ensure that work is completed within specified time and quality parameters.
- Removes obstacles in order to move the work forward and/or get efforts back on track.
- Surfaces problems and issues before projects get derailed.

PHYSICAL REQUIREMENTS

The physical requirements described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Must be able to operate general office equipment including but not limited to: computer, phones and related media and information devices.
- Ability to communicate both in person and/or by telephone.

CB1

ermHO
]]>Sat, 18 May 2013 05:31:00 GMThttp://www.amerigroup-jobs.com/job/Norfolk-Director-HCMS-Behavioral-Health-Job-VA-23501/2362478/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSShttp://www.amerigroup-jobs.com/job/Norfolk-Director-HCMS-Behavioral-Health-Job-VA-23501/2362478/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS
Job ID 2013-22597 # Positions 4
Location US-VA-Virginia Beach
Search Category Customer Service
Type Regular Full-Time (30+ hours) Posted Date 4/16/2013
Additional Locations ..

More information about this job:
Summary:

Under minimal supervision, the Recovery Specialist II is responsible for reviewing claims data to identify, confirm and execute the recovery of identified overpayments. Performs all authorized duties in the processing of overpayments allocated to the assigned market consistent with all applicable company and departmental policies.

Responsibilities:

1. Researches claims data to identify potential overpayments to providers through independent work and/or with other departments or work groups.

2. Maintains working knowledge of all company products and services pertaining to business segment.

3. Prepares and submits productivity and savings reports.

4. Meets or exceeds established productivity and quality.

5. Prepares and sends correspondence to Providers notifying of claims overpayment(s).

6. Work with health plans regarding overpayment Provider disputes.

7. Communicates with Providers regarding overpayment disputes, on occasion.

8. Adheres to company and department policies and procedures, as well as state and federal regulations.

9. Performs other duties as requested or assigned.

Qualifications:

EDUCATION AND EXPERIENCE

Education

Required:
- High school diploma or GED.

Preferred:
- Associate’s degree or Medical coding coursework.

Years and Type of Experience Required:

Required:
- Four years medical claims processing or medical billing or collections experience, or demonstrated proficiency as an Recovery Specialist I.

Language Skills

Required:
- English

TECHNICAL COMPETENCIES

Computer Skills and Office Equipment
- Ability to use software and hardware of a computer to complete certain simple tasks.
- Able to use basic office equipment such as telephone, fax machine and copy machine.
- Working knowledge in a windows environment to include navigation skills using a mouse, keyboard, 10 key and typing at 35 words/minute.
- Use of internet and some familiarity with SharePoint sites.
- Ability to review and draft correspondence in email system and word processing systems.
- Ability to use spreadsheets to open, review, edit and save data.
- Ability to use software for data analysis, reporting and sharing of information to problem solve.
- Ability to create and manipulate spreadsheets (i.e., data entry and format cells).

Read, Interpret and Apply Information
- Ability to research information using available resources.
- Read and comprehend the information to analyze and apply logical thinking in making sound decisions.
- Understand and apply general instructions to appropriately and accurately process adjustments.
- Capacity to follow step-by-step directions, remain detail oriented and verify data from EOB's including HIPAA documentation.
- Ability to investigate and review claim from initial receipt.
- Ability to apply in-depth problem solving with more complex claims.
- Ability to read and interpret contract terms as related to payment policies for outpatient and inpatient claims.

Medical, Recovery & Billing Terminology
- Understanding of medical terminology used in claims documentation.
- Knowledge of other healthcare companies and third party insurance.
- Some understanding of Cost Containment/Overpayment processes, such as COB.
- Familiarity with claims medical coding.
- Working knowledge of recovery practices.

System Familiarity
- Ability to use a claims adjudication system to process claims, such as Facets.
- Familiarity with image repository-review systems for the retrieval of documents.
- Ability to identify system issues to management for problem solving

COMMUNICATION SKILLS:

Verbal, Written and Telephonic
- Ability to use proper language, grammar and style in the preparation of verbal and written messages to clearly, effectively and professionally convey an appropriate message.
- Skills to properly handle telephone inquiry with customers (providers, vendors and other health insurance carriers).

BEHAVIORAL COMPETENCIES

Strategic Leadership

Be Strategic
- Demonstrates understanding of the organization's mission and strategies.
- Works to clarify and understand the broader purpose and mission of own work.
- Integrates and balances big-picture concerns with day-to-day activities.
- Generates innovative ideas and solutions to problems.
- Identifies opportunities to increase efficiency, simplicity, and revenue.

Make Sound Decisions
- Approaches problems with curiosity and open-mindedness.
- Collects sufficient information to understand problems and issues.
- Analyzes problems and issues from different points of view.
- Applies accurate logic and common sense in making decisions.

People Leadership

Develop/Support Organizational Talent
- Relates to people in an open, friendly, and accepting manner.
- Treats others with respect.
- Listens carefully and attentively to others’ opinions and ideas.
- Maintains positive relationships even under difficult or heated circumstances.
- Works cooperatively with people from different cultural backgrounds.

Ensure Collaboration
- Encourages people to draw on each other's strengths and experience to work together effectively, within and across teams.
- Appropriately involves others in decisions and plans that affect them.
- Provides honest, helpful feedback to others on their performance.
- Shares own experience and expertise with others.

Results Leadership

Show Drive and Initiative
- Demonstrates a "can-do" spirit, a sense of optimism, ownership, and commitment.
- Maintains a consistent, high level of productivity.
- Takes personal responsibility to make decisions and take action.
- Does not easily give up in the face of unexpected obstacles.
- Projects a positive image and serves as a role model for others.

Accountability / Optimize Execution
- Juggles many priorities and competing demands for one's time.
- Acts resourcefully to ensure that work is completed within specified time and quality parameters.
- Removes obstacles in order to move the work forward and/or get efforts back on track.
- Surfaces problems and issues before projects get derailed.

PHYSICAL REQUIREMENTS

The physical requirements described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Must be able to operate general office equipment including but not limited to: computer, phones and related media and information devices.
- Ability to communicate both in person and/or by telephone.
- Must be able to travel as needed and adhere to AMERIGROUP travel policies and procedures.

ermCS
]]>Wed, 15 May 2013 02:59:00 GMThttp://www.amerigroup-jobs.com/job/Virginia-Beach-Recovery-Specialist-II-Job-VA-23450/2549311/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSShttp://www.amerigroup-jobs.com/job/Virginia-Beach-Recovery-Specialist-II-Job-VA-23450/2549311/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS
Job ID 2013-22816 # Positions 1
Location US-VA-Virginia Beach
Search Category Customer Service
Type Regular Full-Time (30+ hours) Posted Date 5/10/2013
Additional Locations ..

More information about this job:
Summary:

Provides leadership, strategic planning and direction for vendor contracts within Cost Containment and related services. These functions include, but are not limited to research, contracting, implementations, recovery processes, and outcome reporting to department and senior operations management. Fosters collaborative relationships with each health plan and internal departments to ensure cost containment activity and recovery efforts are completed within all company, state and federal requirements.

Responsibilities:

1. Researches and identifies appropriate vendor solutions for cost containment initiatives.

2. Directs all vendor functions related to the identification and recovery of overpayments.

3. Negotiates contract terms and conditions with vendors primarily for but not limited to cost containment.

4. Ensures compliance with Amerigroup policies and procedures including Legal and Regulatory compliance and signoff. Ensures that the most effective financial terms are achieved, and that all state compliance-related issues are met.

5. Executes all vendor contracts from initial analysis and budgeting through implementation.

6. Monitors contract performance relevant to delivery schedules, applicable laws, payment provisions, performance metrics, and other pertinent requirements.

7. Responsible for the on-going evaluation and management of reimbursement recovery opportunities related to vendor projects through direct management and direction of staff.

8. Directs the research and resolution of escalated provider complaints, identifying trend patterns and creating corrective action plans to address root cause issues related to vendor projects.

9. Validates all vendor invoices in compliance with contract terms and recovery accuracy, ensuring recoupment is completed prior to payment.

10. Directs staff in the collection of provider negative balances, and interface with the provider, health plan provider relations staff, claims, legal, finance and other departments as needed.

11. Coordinates formal responses to vendor recovery questions/issues by health plans, states, etc. including matters of subrogation and coordination of benefits.

12. Achieves departmental/corporate goals through the ongoing selection, performance management and development of employees, including personal development and leadership skills.

13. Performs other duties as assigned.

Qualifications:

EDUCATION AND EXPERIENCE

Education

Required:
- Bachelor’s degree in related field or equivalent experience.

Years and Type of Experience Required:

Required:
- Eight years of experience with health insurance claims and/or recovery, with a minimum of three years in a managed care organization.
- Five years of leadership and/or management experience.

Language Skills

Required:
- English

Technical Competencies

Computer Skills and Office Equipment
- Ability to use software and hardware of a computer to complete certain moderately-complex to complex tasks.
- Able to use basic office equipment such as telephone, fax machine and copy machine.
- Working knowledge in a windows environment to include navigation skills using a mouse, keyboard, 10 key and typing at 35 words/minute.
- Use of internet and some familiarity with SharePoint sites.
- Ability to review and draft correspondence in email system and word processing systems.
- Ability to use software for data analysis, reporting and sharing of information to problem solve.
- Ability to create and manipulate spreadsheets (i.e., data entry and format cells).
- Ability to work in databases.

Read, Interpret and Apply Information
- Ability to research information using available resources.
- Read and comprehend the information to analyze and apply logical thinking in making sound decisions.
- Understand and apply general instructions to appropriately and accurately process claims.
- Capacity to follow step-by-step and general directions, remain detail oriented and verify data from EOB's including HIPAA documentation.
- Ability to investigate and review claim from initial receipt.
- Ability to apply in-depth problem solving with more complex claims.
- Ability to read and interpret contract terms as related to payment policies for outpatient and inpatient claims.

Medical, Recovery & Billing Terminology
- Understanding of medical terminology used in claims documentation.
- Knowledge of other healthcare companies and third party insurance.
- Understanding of Cost Containment/Overpayment processes, such as COB.
- Familiarity with claims medical coding.
- Working knowledge of recovery practices.
- Understand DRG, capitation - per diem rules.
- Understand the different levels of care and applicable payment methodology.

System Familiarity
- Ability to use a claims adjudication system to process claims, such as Facets.
- Familiarity with an image repository-review system for the retrieval of documents.
- Ability to identify system issues to management for problem solving.
- Understanding of the system configuration concepts for benefits, pricing, and provider set up.

Communication Skills

Verbal, Written and Telephonic
- Ability to convey complex messages to a variety of audiences in an effective manner using proper language, grammar and style in the preparation of verbal and written messages.
- Skills to properly handle telephone inquiry with customers (providers, vendors and other health insurance carriers).
- Ability to prepare, edit and convey a variety of messages including presentations, settlement materials and updates.
- Ability to handle escalated issues through verbal and written messages.

Behavioral Competencies

Strategic Leadership

Be Strategic
- Integrates and balances big-picture concerns with day-to-day activities.
- Conveys a thorough understanding of own area's strengths, weaknesses, opportunities, and threats.
- Evaluates and pursues initiatives, investments, and opportunities based on their fit with broader strategies.
- Stays abreast of key competitor actions and their implications or threats to the business.

Make Sound Decisions
- Focuses on important information without getting bogged down in unnecessary detail.
- Probes and looks past symptoms to determine the underlying causes of problems and issues.
- Brings to bear the appropriate knowledge, information, and expertise in making decisions.

People Leadership Develop / Support Organizational Talent
- Identifies the qualifications required for successful job performance.
- Provides honest, helpful feedback to others on their performance.
- Helps others identify and prioritize their development objectives.
- Promotes sharing of expertise and a free flow of learning across the organization.

Ensure Collaboration
- Discourages "we vs. they" thinking.
- Appropriately involves others in decisions and plans that affect them.
- Works to remove barriers to collaboration.
- Seeks to understand and address the concerns and interests of others with opposing viewpoints.

Results Leadership Show Drive and Initiative
- Does not easily give up in the face of unexpected obstacles.
- Sets high standards of performance for self and others.
- Puts in extra effort and work to accomplish critical or difficult tasks.
- Tackles tough challenges or problems quickly and directly.

Accountability/Optimize Execution
- Conveys clear expectations for assignments.
- Delegates assignments to the lowest appropriate level.
- Monitors progress of others and redirects efforts when goals change or are not met.
- Holds people accountable for achieving their goals.

SCOPE INFORMATION

# Direct Reports: 4

# Indirect Reports: 50-60

Budgetary $ Responsibility: $4-10 million

PHYSICAL REQUIREMENTS

The physical requirements described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Must be able to operate general office equipment including but not limited to: computer, phones and related media and information devices.
- Ability to communicate both in person and/or by telephone.
- Must be able to travel as needed and adhere to Amerigroup travel policies and procedures.

ermCS
]]>Fri, 10 May 2013 00:00:00 GMThttp://www.amerigroup-jobs.com/job/Virginia-Beach-Director-Cost-Containment-Job-VA-23450/2592118/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSShttp://www.amerigroup-jobs.com/job/Virginia-Beach-Director-Cost-Containment-Job-VA-23450/2592118/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS
Job ID 2013-22619 # Positions 40
Location US-VA-Virginia Beach
Search Category Customer Service
Type Regular Full-Time (30+ hours) Posted Date 4/18/2013
Additional Locations ..

More information about this job:
Summary:

Associates are focused on understanding and meeting the needs of our customers by connecting with the mission and vision in their daily work activity. Claims associates are not only processors, but are challenged to use their analytical skills to identify issues and proactively engage to solve problems that may negatively impact our customers. While anticipating the needs of our customers, Claims associates will be skilled in the uniqueness of their markets to insure that every claim is handled appropriately and accurately, with the goal of “treating each claim as a member”. While meeting production goals is important and necessary, at Amerigroup, Claims associates will connect their work with the impact on our customers to create an amazing customer experience.

If you are looking for a way to make a difference in the lives of others by offering a little help to those in need, you are invited to further explore employment opportunities at Amerigroup.

Under general supervision, analysts evaluate simple to moderately complex claims to determine the type and amounts of benefits payable. You will perform all authorized duties in the processing of claims allocated to the assigned market consistent with all applicable company and departmental policies.

This requisition is posted for candidates interested in a traning class in Virginia Beach during the 2nd quarter of 2013.

Responsibilities:

1. Researches and processes all intermediate level claims transactions. Processing includes most claim types with the exception of inpatient, transplant, dialysis and hospice.

2. Processes correspondence and customer service inquiries as it relates to the above claims transactions.

3. Processes primary care encounter information and fee for service claims received in both paper and automated formats into claims systems.

4. Accurately interprets, understands and applies product contracts and fee schedules for assigned markets when processing claims.

5. Interprets and applies explanation of benefits (EOB) statements from other carrier to faciliatate coordination of coverage.

6. Meets or exceeds established quality and production standards.

7. Reviews and responds to quality audits.

8. Responds timely to quality error assignments and provide appropriate documentation to support actions.

9. Performs other duties as assigned.

Qualifications:

EDUCATION AND EXPERIENCE

Education

Required:
- High school diploma or GED.

Preferred:
- Associate’s degree in business or health care field.
- Claims processing/coding certificate program.

Years and Type of Experience Required:

Required:
- One year experience in production or office environment.

Preferred:
- Two years of claims processing experience.

Language Skills

Required:
- English

Technical Competencies

Computer Skills and Office Equipment
- Ability to use software and hardware of a computer to complete certain moderately-complex to complex tasks.
- Able to use basic office equipment such as telephone, fax machine and copy machine.
- Working knowledge in a windows environment to include navigation skills using a mouse, keyboard and 10 key.
- Use of internet, familiarity with SharePoint sites.
- Ability to review and draft correspondence in email system and word processing systems.
- Ability to use software for data analysis, reporting and sharing of information to problem solve.
- Ability to create and manipulate spreadsheets (i.e., data entry and format cells).

Office Math Skills
- Ability to process numbers, which is an essential skill for any problem solving situation in a claims environment.
- Skills in the use of a calculator (using percentages, multiplication and division) to determine appropriate benefit payment.
- Ability to calculate the manual pricing of claims. Skills to verify accuracy with visual percentage calculations.

Read, Interpret and Apply Information
- Ability to research information using available resources.
- Read and comprehend the information to analyze and apply logical thinking in making sound decisions.
- Understand and apply general instructions to appropriately and accurately process claims.
- Capacity to follow step-by-step and general directions, remain detail oriented and verify data including HIPAA documentation.
- Ability to investigate and review claim from initial receipt.
- Ability to apply in-depth problem solving with more complex claims.
- Ability to read and interpret contracts for outpatient and inpatient claims.

Medical & Billing Terminology
- Understanding of medical terminology used in claims documentation.
- Working knowledge of Medicaid and Medicare benefits.
- Familiarity with claims medical coding.
- Knowledge of the different standard claims forms used for physician and hospital billing.
- Understand Coordination of Benefits (COB) and Long term care (LTC) processes.
- Knowledge of state and/or federal guidelines that apply to the Medicaid or Medicare benefits.

Claims System Familiarity
- Ability to use a claims adjudication system to process claims, such as Facets.
- Ability to access documentation through the use of an image repository-review system, such as Macess.
- Ability to apply multiple market information to correctly process claims.
- Ability to identify system issues to management for problem solving.

Behavioral Competencies

Strategic Leadership

Be Strategic
- Demonstrates understanding of the organization's mission and strategies.
- Works to clarify and understand the broader purpose and mission of own work.
- Integrates and balances big-picture concerns with day-to-day activities.
- Generates innovative ideas and solutions to problems.
- Identifies opportunities to increase efficiency, simplicity, and revenue.

Make Sound Decisions
- Approaches problems with curiosity and open-mindedness.
- Collects sufficient information to understand problems and issues.
- Analyzes problems and issues from different points of view.
- Applies accurate logic and common sense in making decisions.

People Leadership

Develop/Support Organizational Talent
- Relates to people in an open, friendly, and accepting manner.
- Treats others with respect.
- Listens carefully and attentively to others’ opinions and ideas.
- Maintains positive relationships even under difficult or heated circumstances.
- Works cooperatively with people from different cultural backgrounds.

Ensure Collaboration
- Encourages people to draw on each other's strengths and experience to work together effectively, within and across teams.
- Appropriately involves others in decisions and plans that affect them.
- Provides honest, helpful feedback to others on their performance.
- Shares own experience and expertise with others.

Results Leadership

Show Drive and Initiative
- Demonstrates a "can-do" spirit, a sense of optimism, ownership, and commitment.
- Maintains a consistent, high level of productivity.
- Takes personal responsibility to make decisions and take action.
- Does not easily give up in the face of unexpected obstacles.
- Projects a positive image and serves as a role model for others.

Accountability / Optimize Execution
- Juggles many priorities and competing demands for one's time.
- Acts resourcefully to ensure that work is completed within specified time and quality parameters.
- Removes obstacles in order to move the work forward and/or get efforts back on track.
- Surfaces problems and issues before projects get derailed.

PHYSICAL REQUIREMENTS

The physical requirements described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Must be able to operate general office equipment including but not limited to: computer, phones and related media and information devices.
- Ability to communicate both in person and/or by telephone.
- Must be able to travel as needed and adhere to Amerigroup travel policies and procedures.

ermCS
]]>Sat, 18 May 2013 05:31:00 GMThttp://www.amerigroup-jobs.com/job/Virginia-Beach-Claims-Analyst-Job-VA-23450/2556791/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSShttp://www.amerigroup-jobs.com/job/Virginia-Beach-Claims-Analyst-Job-VA-23450/2556791/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS