http://www.amerigroup-jobs.com/feeds/Legal-Hampton-Roads-VA-jobs/ Custom RSS Feed for Legal-Hampton-Roads-VA-jobs Thu, 20 Jun 2013 03:32:34 GMT en-us /sites/amerigroup/images/banner.gif http://www.amerigroup-jobs.com/feeds/Legal-Hampton-Roads-VA-jobs/ 720
Job ID 2013-22715 # Positions 1
Location US-VA-Norfolk
US-NATIONWIDE
Search Category Pharmacy
Type Regular Full-Time (30+ hours) Posted Date 4/30/2013
Additional Locations US-NATIONWIDE

More information about this job:
Summary:

Responsible for managing the clinical and operational components of the Amerigroup national pharmacy program Medicare lines of business including prior authorizations and coverage determination programs, pharmacy call center, P&T committee, policies and procedures, Specialty Pharmacy, medication therapy management, retrospective Drug Utilization Review (DUR) programs and Medicare required activities. May interface with the health plans within a Region and participate in other clinical programs and operational activities.

Responsibilities:

1. Responsible for leading the development and management of clinical drug policies and pharmacy programs.

2. Effective management of capital and human resources.

3. Responsible for productivity, operational and quality metrics related to various pharmacy programs. Assists in implementation of corporate and health plan pharmacy MEIs to ensure clinical, quality and financial goals are met.

4. Implementation of point of sale intervention, retrospective drug utilization review, polypharmacy, pharmacist case management, retrospective DUR, medication therapy management, disease management, lock-in and other clinical programs.

5. Develops and implements clinical drug policies and related clinical protocols that assure appropriate utilization and cost control.

6. Develops and implements quality assurance activities to ensure regulatory and clinical policy compliance.

7. Manages the review and presentation of drug therapy class reviews, drug monographs, formulary recommendations and clinical policies for the Pharmacy and Therapeutics Committee.

8. Works with project management teams to ensure new lines of pharmacy business meet all contractual and State requirements.

9. Other Duties as Assigned.

Qualifications:

EDUCATION AND EXPERIENCE

Education

Required:
- BS degree

Preferred:
- BS in Pharmacy or PharmD

Years and Type of Experience Required:

Required:
- Minimum 7 years of Pharmacy, Healthcare, Medicaid or Medicare work experience with at least 3 years leadership/management experience.

Certifications or Licensures

Required: NA

Preferred:
- Licensed and Registered Pharmacist

Language Skills

Required:
- English

Functional Competencies

Required:
- Performs basic data queries and analysis with applications such as Microsoft Access and Excel.
- Proficient in the use of Microsoft Office products, to include Outlook, Word, Excel and PowerPoint.
- Excellent communication and problem solving skills; ability to multi-task and solve complex problems.
- Excellent organizational and analytical skills.

SCOPE INFORMATION

# Direct Reports: 0-8

# Indirect Reports: varies

Budgetary $ Responsibility: As defined

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
]]>Thu, 30 May 2013 08:00:00 GMThttp://www.amerigroup-jobs.com/job/Norfolk-Director-Pharmacy-Medicare-D-Job-VA-23501/2575519/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSShttp://www.amerigroup-jobs.com/job/Norfolk-Director-Pharmacy-Medicare-D-Job-VA-23501/2575519/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS
Job ID 2013-22014 # Positions 1
Location US-VA-Norfolk
Search Category Pharmacy
Type Regular Full-Time (30+ hours) Posted Date 5/13/2013
Additional Locations ..

More information about this job:
Summary:

Responsible for the development and oversight of program operations across all markets with a focus on program development, program enhancements, managing interdependencies and risks, program status and evaluation, reporting, and program growth/expansion in both new and existing markets. Coordinates with leadership across health plans to ensure consistency with (program name) programs.

Responsibilities:

1. Designs, develops, implements and oversees Health Care program operations across all markets in support of corporate and health plan management; responsible for developing and maintaining indicators for monitoring and evaluating quality care, appropriateness, continuous improvement, member satisfaction, utilization, and overall program direction.

2. Establishes annual strategic goals, objectives and work plans in conjunction with senior leadership.

3. Responsible for ensuring development, training, communication, consistency and coordination across markets; creates program documents, gives presentations on (program name) program for a variety of audiences and mentors health plan associates.

4. Participates in the development of professional relationships with community agencies, advocacy groups and participating health plans.

5. Leads various cross functional workgroups created to maintain, enhance, and/or develop programs.

6. Works collaboratively across health plans and corporate towards identification of opportunities for improvement, trend analysis, education and development of appropriate action plans for problems resolution;

7. Serves as liaison with state regulatory agencies, as needed, and assures compliance with state and Federal requirements by collaborating with Corporate Regulatory Compliance and health plans to resolve market issues; has detailed knowledge of (program name) program contract requirements and actively evaluates changes and requests and the potential impact of change to operational areas.

8. Coordinates program deliverables, budget and resources, and is responsible for the resolution of issues that may hinder program success.

9. Other duties as requested or assigned.

Qualifications:

EDUCATION AND EXPERIENCE

Education

Required:
- Bachelor’s Degree in a related discipline with 12 years relevant work experience and at least 7 years of leadership/management experience within a medium to large sized public sector health care organization preferably managed care organizations.

Years and Type of Experience Required:

Required:
- Minimum of twelve years clinical work experience and at least five years of leadership experience in quality management and/or utilization management in a managed care setting.

Certifications or Licensures

Required:
- RN, LCSW, LPC or as defined by the program needs

Preferred:
- RPh/PharmD
- PMP

Language Skills

Required:
- English

Functional Competencies
- Proficient in the use of Microsoft Office products, to include Outlook, Word, Excel and PowerPoint.
- Excellent program management skills, with the capability to effectively manage program and processes across multiple areas of the organization.

SCOPE INFORMATION

# Direct Reports: 2-5

# Indirect Reports: 0-10

Budgetary $ Responsibility: Yes, varies with program

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
]]>Wed, 12 Jun 2013 07:59:00 GMThttp://www.amerigroup-jobs.com/job/Norfolk-VP-Health-Care-Programs-Pharmacy-Job-VA-23501/2428085/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSShttp://www.amerigroup-jobs.com/job/Norfolk-VP-Health-Care-Programs-Pharmacy-Job-VA-23501/2428085/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS
Job ID 2012-19768 # Positions 1
Location US-VA-Norfolk
Search Category Clinical Analyst
Type Regular Full-Time (30+ hours) Posted Date 2/4/2013
Additional Locations ..

More information about this job:
Summary:

To develop, maintain and enhance mechanisms to track, trend, and report quality measures and compliance reports for the health plan(s). To support the continuous quality improvement process needs of the Quality Department and Risk Control and Compliance Operations through comprehensive analysis, documentation and reporting of data pertaining to company performance and compliance goals.

Responsibilities:

1. Collaborates with business data owners to develop, analyze, maintain and submit reports used to measure, monitor and manage quality of care, service, compliance and quality improvement initiatives.

2. Assists in the data analysis, development, reporting and submission of mandatory Health Plan reports to Health and Human Services and other regulators.

3. Manages and validates HEDIS data and projects; assure data integrity and reporting of rates.

4. Develops and utilizes knowledge of databases, information systems, managed care, Medicaid/CHIP population, statistical tools and analytical principles to analyze quality outcomes that support strategies for managing health plan performance.

5. Participates in quality initiatives by assisting with data analysis, project design, inter-rater reliability studies and project documentation.

6. Compiles and analyzes data including comparison of outcome measures to benchmark, identifying trends, completing barrier analysis, and assisting in the identification of activities to reach performance goal. Assures completion, accuracy and timeliness of all reports and data.

7. Performs statistical tests to determine statistical significance, confidence level, validity and reliability of outcome.

8. Supports systems to provide trended data related to member satisfaction, complaint and appeal processes, provider satisfaction, provider access and availability, and other areas required for the quality program evaluation.

9. Conduct troubleshooting with management and IT as problems in data management systems arise to promote consistency in reporting.

10. Participates in clinical focus study development, data collection, analysis and report writing.

11. Coordinates clinical focus study activities, serving as project lead, as assigned.

12. Actively participates in plan-wide or state-wide preparation for accreditation surveys and regulatory audits by creating and maintaining compliance roadmaps, as assigned.

13. Develops, maintains and standardizes reports for State quality and compliance reporting.

14. Functions as expert in QM data retrieval and reporting.

Qualifications:

EDUCATION AND EXPERIENCE

Education

Required:
- Bachelor’s degree in business, science, healthcare or related field preferred. Equivalent experience considered.
- 3-5 years data analysis or statistical experience or successful completion of Amerigroup Leadership Development Program in lieu of years of experience.
- Proficient with window based environment, particularly Microsoft Excel and Access. Working knowledge of information systems including database design.
- Previous HMO/Managed Care industry experience preferred.
- Knowledge of SPSS, Minitab and SQL preferred.
- Understanding of ICD-9 and CPT coding system helpful.

Knowledge and Skills
- Excellent analytic skills, attention to detail.
- Detailed familiarity with computer systems, word processing, spreadsheet, statistical packages and other data base management software.
- Good organizational skills; the ability to handle multiple priorities simultaneously with a high quality result.
- Excellent writing skills.
- Appreciation of cultural diversity towards target population.

PHYSICAL REQUIREMENTS
- Must be able to operate a computer.
- Must be able to operate a telephone.

CB:MW

HEC:DW


]]>Wed, 22 May 2013 07:59:00 GMThttp://www.amerigroup-jobs.com/job/Virginia-Beach-Clinical-Quality-Data-Analyst-Medicare-Job-VA-23450/2043273/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSShttp://www.amerigroup-jobs.com/job/Virginia-Beach-Clinical-Quality-Data-Analyst-Medicare-Job-VA-23450/2043273/?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
]]>Sun, 26 May 2013 08:00:00 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 2013-22141 # Positions 1
Location US-VA-Norfolk
Search Category Customer Service
Type Regular Full-Time (30+ hours) Posted Date 3/14/2013
Additional Locations ..

More information about this job:
Summary:

Provide leadership and expertise in development and maintenance of rules, policies, procedures and educational processes focused on ensuring organizational compliance with industry standard coding practices. Interpret and apply National Uniform Billing Compliance rules, guidelines, laws and industry trends to support accurate provider reimbursement, system configuration, and ongoing provider education. Proactively address cost efficiencies and compliance requirements. Recommend clinical classification and reimbursement guidelines and standards.

Responsibilities:

1. Reviews claims and medical records routed to the department for billing/coding compliance issues; prepares and submits audit findings to appropriate individuals.

2. Correlates findings with appropriate actions including but not limited to provider education, cost recovery, cost avoidance, policy and coverage guidelines.

3. Coordinates findings and actions with Health Plan Medical Director, Provider Relations and other appropriate staff.

4. Assist in the development of departmental policies and procedures regarding documentation and coding standards. Make coding policy recommendations based upon current trends in code theory and interpretation, industry standard coding, billing practices, state contract language (i.e. CPT, HCPCS, Revenue, ICD.9, DRG, etc), medical compliance and reimbursement policies, such as medical necessity issues and proper coding.

5. Assists in evaluation, design and implementation of strategies to send communications to providers who are billing out of normal ranges.

6. Develops appropriate processes and case documentation to support the mission of the department. Present reimbursement coverage recommendations to Reimbursement and Clinical Policy Committees.

7. Provides technical oversight of coding review resources by the medical coding team. Evaluate coding on provider contract rate sheets. Perform quality assurance functions and rate sheet reviews for code recommendations.

8. Creates and maintains code sets used for configuration in benefits & pricing and other sub-systems. Changes to approved code sets are updated accordingly.

9. Ensures all contracts are properly configured in the appropriate business systems for accurate adjudication and reporting. Assists in the resolution of provider contract configuration or claims payment issues identified in the home office or the plans as needed.

10. Interfaces with operational department management, Health Plans and State representatives on industry standards and National Uniform Billing Compliance issues.

11. Assists in provider, provider office staff and Amerigroup staff education process related to medical code assignments, national coding initiatives, industry standards and required documentation.

12. Perform other duties as assigned.

Qualifications:

EDUCATION AND EXPERIENCE

Education

Required:
- Bachelor’s Degree in Health Care Management, Accounting or Business, or equivalent experience in lieu of degree(s).

Years and Type of Experience Required:

Required:
- Minimum of 6 years coding (ICD-9, CPT-4, E&M, HCPCS, DRG and Revenue) experience with a minimum of 2 years experience in claims, clinical or managed care environment.
- Previous experience auditing professional fee coding.
- Previous experience providing physician training and education for E&M coding.

Certifications or Licensures

Required:
- AAPC (CPC) or AHIMA (CC) coding. Must maintain licensure, i.e. completion of annual continuing professional education requirements.

Preferred:
- Licensed Practical Nurse (LPN) or Registered Nurse (RN)

Language Skills

Required:
- English

Functional Competencies
- Intermediate to advanced level MS Office skills.
- Advanced understanding of medical terminology, body systems/anatomy, physiology and concepts of disease.
- Ability to analyze, interpret and summarize contracts, regulations, policies and procedures, reports and legal documents.
- Ability to respond to questions/concern from internal/external customers and regulatory agencies and present company position in understandable and unambiguous manner.
- Prior claims processing system knowledge preferred.
- Ability to apply creative/breakthrough methodologies and thinking to the tasks.
- Strong communication skills, both written and verbal; articulate, persuasive & influential; systematic and timely.

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
]]>Sun, 09 Jun 2013 07:59:00 GMThttp://www.amerigroup-jobs.com/job/Norfolk-Sr-Medical-Coding-Analyst-Job-VA-23501/2480267/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSShttp://www.amerigroup-jobs.com/job/Norfolk-Sr-Medical-Coding-Analyst-Job-VA-23501/2480267/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS
Job ID 2012-20822 # Positions 1
Location US-VA-Norfolk
Search Category Information Technology
Type Regular Full-Time (30+ hours) Posted Date 2/12/2013
Additional Locations ..

More information about this job:
Summary:

Performs general research and analysis to support business operations. Determines best practices and suggests how to improve current practices. Develops recommendations to solve problems and issues related to business operations. Prepare presentations to report findings to a functional or project leadership. Gathers business requirements, performs first level analysis, supporting the development and testing processes of assigned functional areas. Analyzes and reports on moderately complex business problems to be solved with automated systems or other resources.

Responsibilities:

1. Perform requirements gathering, analysis, and process and data flow diagramming for simple processes of moderate complexity.

2. Make recommendations for the Resolution of moderately complex design and functional area organizational issues utilizing department resources, business development lifecycle and development methods and software applications.

3. Read and interpret conceptual, logical, and physical models to include context diagrams, data flow diagrams, process flow diagrams, and logical flow charts.

4. Evaluate and test moderately complex new/modified programs, applications and/or operating systems to ensure adherence to operational specifications. Document and track product defects. Coordinate problem resolution with development and/or product vendors.

5. Read and interpret a design document.

6. Develop and run moderately complex queries and reports for business analysis and trends.

7. Assist in the development of functional test plans used to verify specific system functions according to actual requirements and established guidelines.

8. Function as a liaison for IT and the business and other cross functional resources and departments.

9. Manage multiple priorities.

10. Perform other duties as assigned.

Qualifications:

EDUCATION AND EXPERIENCE

Education

Required:
- Bachelor’s degree in Business Administration, Management Information Systems, Computer Science or a related discipline. Equivalent experience in a Business Analyst role is acceptable in lieu of a degree(s).

Years and Type of Experience Required:

Required:
- Three years experience in business analysis or functional analysis role.

Preferred:
- Health care industry experience.

Certifications or Licensures

Preferred:
- CCBA certification (Certification of Competency in Business Analysis)

Language Skills

Required:
- English

Depending on the business area for a specific position, competency in one or more of the following may be Required:

Technical Competencies
- Demonstrate a basic understanding of core applications and systems.
- Demonstrate proficiency with all applicable company supported software applications.
- Able to provide professional and appropriate written information to internal and external customers.
- Able to initiate conceptual ideas with practical applications.
- Basic knowledge of the inter-relationship among various managed care operational areas.
- Basic knowledge of current technology trends.
- Able to develop and maintain customer relationships.
- Able to identify, analyze, and solve problems and to work with teams to solve problems.
- Able to develop and implement basic project plans.

Computer Skills and Office Equipment - Intermediate
- Ability to use software and hardware of a computer to complete certain simple to moderately-complex tasks. Skills 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 and keyboard. Use of internet. Ability to review and draft correspondence in email system and word processing systems. Ability to use spreadsheets to review, organize and edit data. Ability to use software to conduct data analysis, reporting and sharing of information to solve problems.

Spreadsheet Utilization and Management - Intermediate
- Proficient in use of spreadsheet applications such as Excel including ability to use large data sets, filters to find specific data in a large list and calculation tools.

Database Utilization and Database Management - Novice

Systems - Intermediate
- Understanding of system's utilization and proficient retrieval of information and processing of the following systems:
- NetworX/Facets – build pricing based on provider contracts using Facets applications. Build benefit plans based on State regulations using Facets benefit applications.
- MACESS – contracts and claim images are stored. MACESS Workflow tool for contract life-cycle.
- Software products from Ingenix for prospective payment system (PPS) – pricing.
- Clearquest is used to track projects –knowledge and familiarity using a project inventory tracking system.

Applications/Tools - Intermediate
- Ability to leverage available tools such as:
- TOAD, UltraEdit, Microsoft Project, Microsoft query analyzer SQL mgr, VISIO, (Google), Internet Search, Internet research, use and understand generally accepted templates and BA tools. Powerpoint. SDLC (software development life-cycle), TeamTrack, SharePoint, Ability to go through CNR (change notification request) process.

Industry Knowledge & Familiarity - Basic
- General healthcare, who are our providers (hospitals phy ofc, ancil) who are payors (insurance companies),
- High level claims process, knowledge of general industry how it works.
- More specific knowledge around reimbursement methodology, fee schedules. Per case, per diem, DRG, % of charges, those terms. HIPAA.
- Specific knowledge of code sets such as revenue codes, procedure codes (CPT4, HCPCS, ICD9/10), Diagnoses Related Grouping DRG codes, place of service codes (POS),

Government Programs Specific Knowledge:
- Medicare Medicaid programs, CHIP and LTC.
- Eligible population, general covered services, regulatory body CMS and/or State Medicaid agency.

Gather and Document Requirements - Intermediate
- Ability to prepare simple to moderately-complex requirements documents. Ability to facilitate requirements gathering including determining the most efficient and effective way to capture the requirements, and managing kick off and subsequent status meetings. Ability to manage timelines and due dates. Ability to recognize and understand business changes that impact requirements and incorporate changes into documentation. Ability to read and re-read requirements documents multiple times while maintaining detail orientation.

Contracts - Intermediate
- Ability to read a contract and understand the operational requirements the contract creates. Read, review and understand a contract and tease out requirements from legal verbiage. Contracts are tedious and incumbent needs to be detail oriented and have ability to synthesize what they are reading into action, rules, requirements.

Business Analysis and Problem Solving-Analytics - Basic
- Critical thinking and problem solving methods.

Project Management - Intermediate
- Skilled in running a project utilizing standard project management tools, techniques and methodology. Keeps projects on task.

Testing - Intermediate
- Functions independently in the creation of simple to moderately-complex test plans, including creation of test cases/scripts, setting up data for testing, validation, analyzing test results, integration, end-to-end testing, user acceptance testing (UAT), regression testing, documentation of results and presentation of results to user.

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.

ermIT
]]>Sun, 02 Jun 2013 07:59:00 GMThttp://www.amerigroup-jobs.com/job/Virginia-Beach-PEGA-Operations-Business-Analyst-II-Job-VA-23450/2195331/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSShttp://www.amerigroup-jobs.com/job/Virginia-Beach-PEGA-Operations-Business-Analyst-II-Job-VA-23450/2195331/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS
Job ID 2013-22641 # Positions 1
Location US-VA-Chesapeake
Search Category Health Care Operations
Type Regular Full-Time (30+ hours) Posted Date 4/22/2013
Additional Locations ..

More information about this job:
Summary:

Supports management execution of corporate, divisional, and departmental goals by assisting with opportunity analysis, requirements gathering, collaterals development, training, coaching, and monitoring performance. Performs general research and analysis, and suggests how to improve current practices. Under the direction of National Provider Relations leadership, assists in researching and drafting new Provider Service Organization Policy & Procedures. Experience working with cross-functional teams in a matrix environment a plus.

Responsibilities:

1. Perform requirements gathering, analysis, and process and data flow diagramming for simple processes of moderate complexity.

2. Make recommendations for the Resolution of moderately complex design and functional area organizational issues utilizing department resources, business development lifecycle and development methods and software applications.

3. Read and interpret conceptual, logical, and physical models to include context diagrams, data flow diagrams, process flow diagrams, and logical flow charts.

4. Evaluate and test moderately complex new/modified programs, applications and/or operating systems to ensure adherence to operational specifications. Document and track product defects. Coordinate problem resolution with development and/or product vendors.

5. Read and interpret a design document.

6. Develop and run moderately complex queries and reports for business analysis and trends.

7. Assist in the development of functional test plans used to verify specific system functions according to actual requirements and established guidelines.

8. Function as a liaison for IT and the business and other cross functional resources and departments.

9. Manage multiple priorities.

10. Perform other duties as assigned.

Qualifications:

EDUCATION AND EXPERIENCE

Education

Required:
- Bachelor’s degree in Business Administration, Management Information Systems, Computer Science or a related discipline. Equivalent experience in a Business Analyst role is acceptable in lieu of a degree(s).

Years and Type of Experience Required:

Required:
- Three years experience in business analysis or functional analysis role.

Preferred:
- Health care industry experience.

Certifications or Licensures

Preferred:
- CCBA certification (Certification of Competency in Business Analysis)

Language Skills

Required:
- English

Depending on the business area for a specific position, competency in one or more of the following may be Required:

Technical Competencies
- Demonstrate a basic understanding of core applications and systems.
- Demonstrate proficiency with all applicable company supported software applications.
- Able to provide professional and appropriate written information to internal and external customers.
- Able to initiate conceptual ideas with practical applications.
- Basic knowledge of the inter-relationship among various managed care operational areas.
- Basic knowledge of current technology trends.
- Able to develop and maintain customer relationships.
- Able to identify, analyze, and solve problems and to work with teams to solve problems.
- Able to develop and implement basic project plans.

Computer Skills and Office Equipment - Intermediate
- Ability to use software and hardware of a computer to complete certain simple to moderately-complex tasks. Skills 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 and keyboard. Use of internet. Ability to review and draft correspondence in email system and word processing systems. Ability to use spreadsheets to review, organize and edit data. Ability to use software to conduct data analysis, reporting and sharing of information to solve problems.

Spreadsheet Utilization and Management - Intermediate
- Proficient in use of spreadsheet applications such as Excel including ability to use large data sets, filters to find specific data in a large list and calculation tools.

Database Utilization and Database Management - Novice

Systems - Intermediate

Understanding of system's utilization and proficient retrieval of information and processing of the following systems:
- NetworX/Facets – build pricing based on provider contracts using Facets applications. Build benefit plans based on State regulations using Facets benefit applications.
- MACESS – contracts and claim images are stored. MACESS Workflow tool for contract life-cycle.
- Software products from Ingenix for prospective payment system (PPS) – pricing.
- Clearquest is used to track projects –knowledge and familiarity using a project inventory tracking system.

Applications/Tools - Intermediate

Ability to leverage available tools such as:
- TOAD, UltraEdit, Microsoft Project, Microsoft query analyzer SQL mgr, VISIO, (Google), Internet Search, Internet research, use and understand generally accepted templates and BA tools. Powerpoint. SDLC (software development life-cycle), TeamTrack, SharePoint, Ability to go through CNR (change notification request) process.

Industry Knowledge & Familiarity - Basic
- General healthcare, who are our providers (hospitals phy ofc, ancil) who are payors (insurance companies),
- High level claims process, knowledge of general industry how it works.
- More specific knowledge around reimbursement methodology, fee schedules. Per case, per diem, DRG, % of charges, those terms. HIPAA.
- Specific knowledge of code sets such as revenue codes, procedure codes (CPT4, HCPCS, ICD9/10), Diagnoses Related Grouping DRG codes, place of service codes (POS),

Government Programs Specific Knowledge
- Medicare Medicaid programs, CHIP and LTC.
- Eligible population, general covered services, regulatory body CMS and/or State Medicaid agency.

Gather and Document Requirements - Intermediate
- Ability to prepare simple to moderately-complex requirements documents. Ability to facilitate requirements gathering including determining the most efficient and effective way to capture the requirements, and managing kick off and subsequent status meetings. Ability to manage timelines and due dates. Ability to recognize and understand business changes that impact requirements and incorporate changes into documentation. Ability to read and re-read requirements documents multiple times while maintaining detail orientation.

Contracts - Intermediate
- Ability to read a contract and understand the operational requirements the contract creates. Read, review and understand a contract and tease out requirements from legal verbiage. Contracts are tedious and incumbent needs to be detail oriented and have ability to synthesize what they are reading into action, rules, requirements.

Business Analysis and Problem Solving-Analytics - Basic
- Critical thinking and problem solving methods.

Project Management - Intermediate
- Skilled in running a project utilizing standard project management tools, techniques and methodology. Keeps projects on task.

Testing - Intermediate
- Functions independently in the creation of simple to moderately-complex test plans, including creation of test cases/scripts, setting up data for testing, validation, analyzing test results, integration, end-to-end testing, user acceptance testing (UAT), regression testing, documentation of results and presentation of results to user.

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.

ermHO
]]>Wed, 19 Jun 2013 07:59:00 GMThttp://www.amerigroup-jobs.com/job/Chesapeake-Business-Analyst-II-National-Provider-Relations-Job-VA-23320/2559507/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSShttp://www.amerigroup-jobs.com/job/Chesapeake-Business-Analyst-II-National-Provider-Relations-Job-VA-23320/2559507/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS
Job ID 2013-22952 # Positions 1
Location US-VA-Richmond
US-VA-Virginia Beach
Search Category Health Care Operations
Type Regular Full-Time (30+ hours) Posted Date 5/24/2013
Additional Locations US-VA-Virginia Beach

More information about this job:
Summary:

The AVP, Operations will report directly to the COO with a dotted line to the SVP, Operations. The incumbent will work to advance AMERIGROUP’s strategic imperatives as the primary link between the HO and health plan operations. The incumbent will be responsible for health plan dashboards, operations policies, OPEX, best practices and regulatory compliance. The incumbent will build strong working relationships with plan senior management and HO support areas to assist in meeting the goals of the organization. In addition, the incumbent will demonstrate high levels of flexibility by managing projects at the health plan based on strategic priorities. The incumbent will be responsible for identifying and prioritizing health plan opportunities for improvement in the areas of efficiency and effectiveness.

Responsibilities:

1. Partners and supports management across the health plan on assigned projects ensuring company goals and initiatives are met.

2. Participates in Operational process improvement initiatives and facilitates collaborative effort between Health Plan and Corporate operations for implementation.

3. Demonstrate mastery of process improvement methodology (i.e. Six Sigma certification) in appropriate timeframe as directed by management.

4. Works with health plan operations to ensure appropriate key operational indicators are in place for monitoring and analysis.

5. Maintains health plan dashboard of key operational indicators, identifies and reports issues to management.

6. Identifies opportunities for Operational Excellence and works to create seamless processes between HO and the health plan.

7. Works with HO support areas/account managers to resolve operational issues to include enrollment, benefit configuration, call metrics, authorizations, high dollar claims, pended claims, CAMP, appeals, adjustments customer service and policy issues.

8. Assists Health Plan Provider Relations with the resolution of defects resulting from the provider contract request, configuration and implementation processes.

9. Engages in corporate cost containment initiatives by identifying opportunities to maximize dollar recovery.

10. Maintains awareness of HO initiatives to ensure priority alignment and promotes health plan communication and collaboration.

11. Recognizes and utilizes appropriate channels for communication, encourages two-way communication with Plan and Home Office staff to participate in creative program development resulting in improved efficiency and enhanced job performance.

Qualifications:

EDUCATION AND EXPERIENCE

Education

Required:
- Bachelor’s Degree or equivalent experience in Business, Health Care or related field.

Preferred:
- Master’s Degree

Years and Type of Experience Required:
- Minimum of eight years work related experience.
- Project management or leadership experience in a medium to large size business environment.
- 3-5 years of demonstrated experience in data assimilation & analysis
- Experience with change management.

CERTIFICATION AND LICENSURE

Preferred:
- Black belt quality certification.

Knowledge and Skills
- Excellent analytical, organizational, problem-solving, and communication skills.
- Ability to demonstrate political sensitivity and to work effectively with senior level management as well as with multi-disciplinary teams across department lines.
- Demonstrated leadership in healthcare operations including claim payment and root cause identification.
- Strong leadership, coaching, and staff development skills.
- Strong knowledge of data management and interpretation.
- Conflict resolution/mediation experience.
- Clinical or coding skills a plus.
- Quality training a plus.

PHYSICAL REQUIREMENTS
- Must be able to operate a computer.
- Must be able to operate a phone.
- Ability to travel a minimum of 25%, as require.

CB1

ermHO
]]>Tue, 28 May 2013 05:00:00 GMThttp://www.amerigroup-jobs.com/job/Richmond-AVP-Health-Plan-Operations-Job-VA-23173/2622948/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSShttp://www.amerigroup-jobs.com/job/Richmond-AVP-Health-Plan-Operations-Job-VA-23173/2622948/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS
Job ID 2013-23014 # Positions 1
Location US-VA-Virginia Beach
Search Category Human Resources
Type Regular Full-Time (30+ hours) Posted Date 6/3/2013
Additional Locations ..

More information about this job:
Summary:

Under general direction, responsible for day-to-day administration of policies and programs covering several or all of the following: recruiting, compensation and benefits, training, employee relations. Partners with assigned client groups to gain understanding of client's business in order to effectively support, propose and lead initiatives that support business unit objectives and success.

Responsibilities:

1. Partners with assigned client groups to gain understanding of client's business in order to effectively support, propose and lead initiatives that support business unit objectives and success.

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. Partner with assigned business unit to support associate development and establish development plans, career paths and retention programs.

4. Assess and make recommendations for organizational structure based on talent and organizational goals.

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

6. Conduct timely investigations into complaints of ADA, EEO, Workplace Harassment and other associate concerns.

7. Conduct recruitment activities including identification and selection of suitable candidates to fill open positions in conjunction with recruiting staff and/or consultants. Provide salary recommendation for potential hires and extends employment offers to qualified/selected candidates. Manage internal applicant process and provide feedback/follow-up to associates regarding application status.

8. Provide consultation to management in regards to performance reviews, compensation changes/adjustments, merit increases and promotional increases for consistency and compliance with company policy and legal considerations.

9. Facilitate New Hire Orientation sessions to review Company expectations/ guidelines, as well as Corporate Policies and Procedures.

10. Implements and manages the coordination of Human Resources programs, policies and systems as assigned.

11. Other duties as assigned.

Qualifications:

EDUCATION REQUIRED

Education

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

Years and Type of Experience Required:

Required:
- Minimum 5 years of related experience

Specific Technical Skills

Required:
- Excellent computer skills including Microsoft Office Suite

Preferred:
- Experience working with PeopleSoft

Certifications or Licensures

Preferred:
- PHR or SPHR

Other:

Required:
- Strong Employee Relations background and knowledge to include: federal and state employment laws, NLRA, FLSA, EEO, FMLA laws, etc. required.
- Comprehensive knowledge of compensation, benefits administration, employment and HR administration.
- Ability to assess and develop solutions for organizational development and training needs.
- 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.
- Previous experience in working within a highly-matrixed environment. Ability to deliver by managing through others.
- Appreciation of cultural diversity and sensitivity towards target population.

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
]]>Mon, 03 Jun 2013 05:00:00 GMThttp://www.amerigroup-jobs.com/job/Virginia-Beach-Manager-Human-Resources-Job-VA-23450/2636863/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSShttp://www.amerigroup-jobs.com/job/Virginia-Beach-Manager-Human-Resources-Job-VA-23450/2636863/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS
Job ID 2013-23109 # Positions 1
Location US-VA-Virginia Beach
US-NJ-Iselin
Search Category Legal
Type Regular Full-Time (30+ hours) Posted Date 6/13/2013
Additional Locations US-NJ-Iselin

More information about this job:
Summary:

Under limited supervision, conduct in-depth investigations of reported, alleged or suspected fraud, waste and abuse involving providers, members, and associates for the full range of products at Amerigroup. Ensure compliance with contractual requirements related to Corporate Investigations Department (CID) and fraud, waste and abuse investigations. Mentors and provides guidance to others in the unit. Develops and maintains working relationships with appropriate Health Plans, departments and outside agencies.

Responsibilities:

1. Maintains full investigative moderate to complex case load by conducting investigations into reported, alleged or suspected fraud, waste and abuse.

2. Independently decides the most effective and efficient method of investigation for each individual case. Prepares and documents investigative plans detailing the investigative plan of action according to department guidelines.

3. Proactively and independently analyzes data using available fraud detection software and corporate resources to identify new cases and as part of the investigative process.

4. Performs out-of-office field investigation, as appropriate.

5. Develops sufficient evidence to conclusively establish facts.

6. Independently conducts and documents comprehensive interviews/interrogations with providers, members, associates and witnesses to obtain information which would be considered admissible under generally accepted criminal and civil rules of evidence.

7. Prepares and submit findings and make recommendations to management.

8. Manages assigned cases and continuously updates the department’s Case Management System, along with the physical and on-line case files, with pertinent case details.

9. Testifies in criminal and civil legal proceedings as required.

10. Works in collaboration with the Medical Directors, Quality Management, Clinical Review specialist, and Certified Professional Coders (CPC) in order to quantify and qualify properly identified overpayment amounts.

11. Utilizes the Rats Stats application to properly identify the accepted legal sample(s) and overpayment that may have to be reproduced in the judicial arena.

12. Represents Amerigroup in conducting settlement negotiations with providers, counsel and/or other associated parties.

13. Prepares, collects, organizes, develops and submits any and all documentation in accordance with required State and Federal audits.

14. Prepares, documents, and submits required monthly/quarterly reports to identified state agencies, upper management within Amerigroup and federal agencies, if requested.

15. Establishes and maintains working relationships with all appropriate law enforcement and regulatory personnel, and industry peers including FBI, Attorney General’s Office, Departments of Insurance, State Special Investigations Units, NHCAA and other managed care organizations in their respective markets.

16. Develops and maintains close working relationships with all internal departments and senior management in the health plan(s) to which they are assigned including CEOs, Chief Compliance Officers, Medical Directors, Provider Relations, and Claims etc.

17. Develops and maintains working relationships with Amerigroup vendors relating to coordinating investigations.

18. Represents Amerigroup at meetings with state agencies, law enforcement, and other out side entities.

19. Conducts special studies for management such as those required to determine compliance with new provider contracts, laws or regulations.

20. Develops and presents fraud awareness training sessions.

21. Provides consultation to Investigators where high level technical expertise is necessary. Assists with training, and educating other associates in the department.

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

23. Participates in the preparation of responses related to the development of Request for Proposals, Expansion Applications and Readiness Reviews in new Markets.

24. Assists in the evaluation, design and implementation of strategies to flag and evaluate claims of certain providers who are billing beyond norms prior to disbursement of payments. Additionally, assist in sending communications/training to providers regarding billing beyond norms and monitor impact on future billing patterns.

25. Continuously identifies opportunities to reengineer current practices (process improvement).

26. Performs other duties as assigned/requested.

Qualifications:

EDUCATION AND EXPERIENCE

Education

Required:
- Bachelor’s degree or equivalent work experience accepted in lieu of education.

Years and Type of Experience Required:

Required:
- Minimum 5 years experience in the field of Criminal Justice, Business, Insurance, Medical Insurance Claims, Clinical or other related field.

Preferred:
- Minimum 5 years experience conducting health care or white collar crime investigations interacting with state, federal and local law enforcement agencies with law enforcement experience and/or clinical experience.

Certifications or Licensures

Preferred:
- Accredited Health Care Fraud Examiner (AHFI)
- Certified Fraud Examiner (CFE)

Language Skills

Required:
- English

Functional Competencies
- Intermediate to Advanced Level of MS Office skills.
- AMISYS, FACETS or related claims processing system preferred.
- Understanding of CMS 1500 and UB04 claim billing forms.
- Advanced understanding of common claim coding (CPT-4, ICD-9, HCPCS)
- Knowledge of Medicare and Medicaid insurance law, federal, state, civil and criminal statutes.

SCOPE INFORMATION

# Direct Reports: 0

# Indirect Reports: 0

Budgetary $ Responsibility: 0

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 25%) and adhere to Amerigroup travel policies and procedures.

ermCorp
]]>Thu, 13 Jun 2013 05:00:00 GMThttp://www.amerigroup-jobs.com/job/Virginia-Beach-Senior-Investigator-Job-VA-23450/2662598/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSShttp://www.amerigroup-jobs.com/job/Virginia-Beach-Senior-Investigator-Job-VA-23450/2662598/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS
Job ID 2013-23129 # Positions 1
Location US-VA-Virginia Beach
US-NJ-Iselin
US-CA-Newbury Park
Search Category Legal
Type Regular Full-Time (30+ hours) Posted Date 6/17/2013
Additional Locations US-NJ-Iselin
US-CA-Newbury Park

More information about this job:
Summary:

Under direct supervision, conduct in-depth investigations of reported, alleged or suspected fraud, waste and abuse involving the full range of products at Amerigroup Ensure compliance with contractual requirements related to Corporate Investigations Department (CID) and fraud, waste, and abuse investigations. Develops and maintains working relationships with appropriate Health Plans, departments and outside agencies.

Responsibilities:

1. Maintains investigative simple to moderately complex case load by conducting investigations into reported, alleged or suspected fraud, waste, and abuse.

2. Partners with CID Management to determine the most effective and efficient method of investigation for each individual case.

3. Prepares and documents investigative plans detailing the investigative plan of action according to department guidelines.

4. Develops sufficient evidence to conclusively establish facts.

5. Partners with Senior Investigators and/or CID Management to conduct comprehensive interviews/interrogations with providers, members and witnesses to obtain information which would be considered admissible under generally accepted criminal and civil rules of evidence.

6. Analyzes data as part of the investigative process using available fraud detection software and corporate resources.

7. Utilizes the Rats Stats application to properly identify the accepted legal sample(s) and overpayment that may have to be reproduced in the judicial arena.

8. Prepares and submits findings and make recommendations to management.

9. Works in collaboration with the Medical Directors, Quality Management, Clinical Review specialist, and Certified Professional Coders (CPC) in order to quantify and qualify properly identified overpayment amounts.

10. Establishes and maintains working relationships with all appropriate law enforcement and regulatory personnel, and industry peers including FBI, Attorney General’s Office, Departments of Insurance, State Special Investigations Units, NHCAA and other managed care organizations in their respective markets.

11. Develops and maintains close working relationships with all internal departments and senior management in the health plan(s) to which they are assigned including CEOs, Chief Compliance Officers, Medical Directors, Provider Relations, and Claims etc.

12. Conducts special studies for management such as those required to determine compliance with new provider contracts, laws or regulations.

13. Assists in the development and presentation of fraud awareness training sessions.

14. Manages assigned cases and continuously update the department’s Corporate Investigation Management System, along with physical and on-line case files, with pertinent case details.

15. Assists in the preparation, documentation, and submission of monthly/quarterly reports to identified state agencies, upper management within Amerigroup and federal agencies, if requested.

16. Performs out-of-office field investigation, as appropriate.

17. May represent Amerigroup at meetings with state agencies, law enforcement, and other outside entities.

18. May testify in criminal and civil legal proceedings.

19. Perform other duties as assigned or requested.

Qualifications:

EDUCATION AND EXPERIENCE

Education

Required:
- Bachelor’s degree or equivalent work experience accepted in lieu of education.

Years and Type of Experience Required:

Required:
- Minimum 1 years experience in the fields of Criminal Justice, Business, Insurance, Medical Insurance Claims, Clinical, or other related fields.

Preferred:
- Minimum 1 years experience conducting health care or white collar crime investigations interacting with state, federal and local law enforcement agencies with law enforcement experience and/or clinical experience.

Certifications or Licensures

Preferred:
- Accredited Health Care Fraud Examiner (AHFI)
- Certified Fraud Examiner (CFE)

Language Skills

Required:
- English

Functional Competencies
- Intermediate level of MS Office skills.
- AMISYS, FACETS or related claims processing system preferred.
- Understanding of CMS 1500 and UB04 claim billing forms.
- Advanced understanding of common claim coding (CPT-4, ICD-9, HCPCS).
- Knowledge of insurance law federal, state, civil and criminal statutes.

SCOPE INFORMATION

# Direct Reports: 0

# Indirect Reports: 0

Budgetary $ Responsibility: 0

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 25%) and adhere to Amerigroup travel policies and procedures.

ermCorp
]]>Mon, 17 Jun 2013 05:00:00 GMThttp://www.amerigroup-jobs.com/job/Virginia-Beach-Investigator-Job-VA-23450/2672261/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSShttp://www.amerigroup-jobs.com/job/Virginia-Beach-Investigator-Job-VA-23450/2672261/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS
Job ID 2013-23104 # Positions 1
Location US-VA-Virginia Beach
US-NV-Las Vegas
Search Category Legal
Type Regular Full-Time (30+ hours) Posted Date 6/13/2013
Additional Locations US-NV-Las Vegas

More information about this job:
Summary:

Under general direction:
- Manages small scale new market/new product development projects or segments of larger scale development projects in support of Amerigroup’s (AGP’s) strategic growth and development initiatives; or
- Manages the regulatory services program of a single operational market. Supports AGP’s compliance with the regulatory and contractual obligations of multiple state and federal regulatory bodies. Serves as a liaison with state regulators, and the primary communication vehicle for educating Corporate /Health Plan management staff on regulatory/contractual requirements, operational or implementation issues, and recommended actions to develop or support compliant activity by active management of the full spectrum of the market’s regulatory activities required for successful “go-live” or ongoing operations. Manages the day to day activities of assigned team members.

Responsibilities:

1. Develop and manage the regulatory services program for a single operational market. Lead activities in support of AGP’s understanding of and compliance with federal and state regulatory requirements, contractual obligations that AGP is subject to as a licensed Managed Care Organization and state contractor.

2. Operate as the internal subject matter expert in the education of health plan and corporate staff on market and product specific regulatory and contractual requirements.
- Participate as a key member of health plan senior management teams and/or implementation teams for development projects.
- Provide key stakeholders with information and resource tools to promote informed and strategic decision making and planning.
- Actively participate in a broad spectrum of health plan and corporate initiatives and workgroups to resolve operational issues to include enrollment, benefit configuration, call metrics, authorizations, high dollar claims, pended claims, appeals, and policy issues.

3. Serve as primary company representative for state regulatory agencies and personnel –
- Act as a key contact for the state and internally manage all state submissions for development projects or ongoing operations including but not limited to: regulatory filings, AGP requests for clarification on operational requirements, proposed corrective action plans, and responses to state agency requests for information.
- Develop and maintain productive working relationships with key regulators charged with initial application review/licensing approval, contract administration, and ongoing regulatory oversight of AGP to ensure effective state agency/company collaboration benefiting AGP development opportunities and ongoing operations.

4. Research and document licensing and operational requirements, developing and/or maintaining customer-focused resource tools for the purpose of associate education, executive decision-making and compliance assessments to support the implementation and maintenance of compliant business operations (i.e., State Requirements Grids, reporting grids, Alerts, Contract Summaries and SharePoint work sites).

5. Develop and maintain effective and ongoing working relationships with key health plan and corporate staff which may include, but are not limited to, Health Plan CEO/COO, Plan Compliance Officer(s), Government Relations staff, and Implementation staff. Interfaces with senior management to promote contract/regulatory compliance, address key regulatory issues and strategize for successful resolution to achieve department and company goals.

6. Research and document licensing requirements and subsequently manage the preparation, submission and approval process of the initial licensure and certification applications or renewal filings necessary for market entry or ongoing health plan operations (Certificate of Authority, Third Party Administrator, Utilization Review Agent).
- Ensure regulatory requirements are defined;
- Identify/attain agreement on business owner accountability for deliverables;
- Review application content for compliance with state specific requirements; and
- Project manages the application submissions and revisions through the regulatory approval process.

7. Lead/co-lead the review, preparation and submission of desktop audit and readiness review materials required for new contract implementations or scheduled operational audits.
- Meeting same criteria as listed in responsibility #6 above;
- Active participant in audit preparations and on-site regulatory agency reviews;
- Active participant in developing responses and corrective action plans to identify deficiencies.

8. Lead the review, assessment, communication and understanding of new or revised state regulations, state Medicaid/CHIP contracts and amendments and other state issued guidance material and leads/supports implementation activity.
- Manage the state contact execution, amendment and renewal process, including the coordination and submission of required documentation and certifications necessary for state approval.

9. Support the development of AGP proposals for new markets and products or reprocurements of existing business through the review of proposal drafts and preparations of regulatory deliverables for inclusion in the proposal(s), as applicable.

10. Oversee the state complaint coordination process, as applicable:
- Monitor the volume, trends and other pertinent information related to complaints received from state regulatory agencies;
- Ensure complaints are tracked, triaged and resolved in a timely and comprehensive manner; and
- Provide review and approval of response documentation prior to state agency submission.

11. Oversee regulatory filings of marketing/advertising materials, member correspondence, outreach programs and other collateral documents and items -
- Review and assess collateral documents for compliance with market or product specific guidelines as a primary reviewer in the Collateral Material Approval Process; and
- Negotiate approvals by state regulatory liaisons as may be necessary.

12. Manage and coordinate the activities of support staff, provide leadership and motivation by establishing clear expectations and communicating specific performance feedback.Provide training and support to team members.

13. Perform other duties as assigned or requested.

Qualifications:

Education

Required:

Bachelor’s degree or equivalent combination of EDUCATION AND EXPERIENCE required.

Years and Type of Experience Required:

Required:

Minimum of 5 years relevant work experience and 1 year of leadership/management experience.

Preferred:

Minimum of 5 years relevant work experience with at least 2 years of managed care industry experience and 1 year of leadership/management experience.

Language Skills

Required:

English

Functional Competencies:
- Intermediate level of MS Office skills; specifically MS Word and Excel
- Strong Internet research skills
- Experience with Microsoft Access database development and maintenance
- Experience with Microsoft Share point page design and maintenance
- Experience with Microsoft Project
- Experience with legal/regulatory databases or search engines

SCOPE INFORMATION
- # Direct Reports: 1-2
- # Indirect Reports: 1+

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, 13 Jun 2013 05:00:00 GMThttp://www.amerigroup-jobs.com/job/Virginia-Beach-Manager-Regulatory-Services-Job-VA-23450/2662601/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSShttp://www.amerigroup-jobs.com/job/Virginia-Beach-Manager-Regulatory-Services-Job-VA-23450/2662601/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS
Job ID 2013-22984 # Positions 1
Location US-VA-Richmond
Search Category Health Care Administration
Type Regular Full-Time (30+ hours) Posted Date 5/31/2013
Additional Locations ..

More information about this job:
Summary:

Responsible for the development, implementation and oversight of integrated Medical Management primarily in the Health Plan. These initiatives will include the establishment of indicators for monitoring and evaluating quality care, appropriateness, continuous improvement, member satisfaction, utilization, and case management across the continuum of care to members. Provides education in the area of healthcare management. Serves as liaison to state regulatory agencies. Participates in accreditation of plan with the National Committee of Quality assurance. Develops professional relationships with community agencies.

Responsibilities:

1. Directs and provides leadership for designing, developing, and implementing the local Plan integrated medical management program to meet the demographic and epidemiological needs of the population serviced.

2. Directs Healthcare Management Program for membership including disease management, case management, and utilization management.

3. Establishes objectives and annual goals in conjunction with the Medical Director to meet objectives established by the Plan CEO/COO and corporate HCMS.

4. Promotes understanding, communication, and coordination of Integrated Medical Management Programs across the health plan.

5. Works with Provider Relations, Quality Management and Health Promotions to develop and implement effective provider communications, quality assurance and member outreach programs.

6. Provides expert consultation to local plan staff on benefits interpretation and utilization and quality management matters.

7. Coordinates on a quarterly basis reporting of quality initiatives to all appropriate plan committees.

8. Ensures support for compliance with National Committee for Quality Assurance (NCQA) and assures compliance with state/and or federal program requirements.

9. Monitors and makes recommendations for oversight of appropriate delegated services.

10. Develops the annual operating and capital budget: ensures that departments stay within budget and accounts for variances.

11. Works collaboratively with key health care professionals toward identification of opportunities for improvement, trend analysis, education and development of appropriate action plans for problems resolution.

12. Other duties as requested or assigned.

Qualifications:

EDUCATION AND EXPERIENCE

Education

Required:
- Bachelors Degree in a health care field or equivalent experience (equivalent experience equates to 6 years related experience in addition to the required 12 years experience).

Preferred:
- Masters Degree in a health care field, or
- MBA with Health Care concentration.

Years and Type of Experience Required:

Required:
- Minimum of 12 years relevant clinical work experience and at least 7 years of leadership/management experience preferably in a managed care setting , with at least 5 years of clinical experience (post Masters for Behavioral Health).
- Previous experience with NCQA accreditation and HEDIS reporting.

Certifications or Licensures

Required:
- RN, LCSW, LPC

Language Skills

Required:
- English

Functional Competencies
- Proficient in the use of Microsoft Office products, to include Outlook, Word, Excel and PowerPoint.
- Excellent problem solving skills; ability to multi-task and solve complex problems.
- Excellent organizational and analytical skills.

SCOPE INFORMATION

# Direct Reports: 5-30

# Indirect Reports: varies

Budgetary $ Responsibility: As assigned

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 HCMS

Job Grade: 23

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

MJO:20%

LTI:15k

ermHO
]]>Fri, 31 May 2013 05:00:00 GMThttp://www.amerigroup-jobs.com/job/Richmond-VP-Healthcare-Mgmt-Svcs-Job-VA-23173/2633191/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSShttp://www.amerigroup-jobs.com/job/Richmond-VP-Healthcare-Mgmt-Svcs-Job-VA-23173/2633191/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS
Job ID 2013-22734 # Positions 1
Location US-VA-Virginia Beach
Search Category Sales & Marketing
Type Regular Full-Time (30+ hours) Posted Date 5/6/2013
Additional Locations ..

More information about this job:
Summary:

The Writer, Communication Services develops concepts and writes copy for Communications collaterals in a variety of formats. Works with VP, Communications, Director/Manager Level Writer, Communications and Art Director/Graphic Designer to write, edit and proofread printed and online materials, before and after design process. Submits all documentation and forms to obtain necessary approvals of text from internal Company business owners and government regulatory agencies.

Responsibilities:

1. Works directly with appropriate staff to ascertain scope of project and analyzes needs of target audience.

2. Writes, edits, proofreads and revises internal and/or external Communications materials, including brochures, RFP sections, web site content, flyers, collaterals, newsletters, companywide emails and presentations, etc.

3. Ensures compliance with strategic initiatives, state and federal regulations to include appropriate key messaging for brand.

4. Submits collateral through the Company’s internal approval process (Collateral Material Approval Process, or CMAP), state and federal government regulatory reviews as appropriate for external audiences.

5. Works with Art Director to develop concepts for to internal and/or external customers.

6. Develops, produces and collaborates with appropriate partners (internal and external) in the writing and production of Requests for Proposals, White Papers, and related materials and projects.

7. Other Duties as Assigned.

Qualifications:

Education

Required:

Bachelor’s degree in English, Communications, Marketing or Healthcare or related field of study.

Years and Type of Experience Required:

Required:

5 years professional writing experience developing targeted communications materials, or equivalent academic experience in pursuit of a higher level degree.

Preferred:

7 years professional writing experience developing materials in healthcare/service industry preferred.

Specific Technical Skills

Required:
- Proficient in Microsoft Word, PowerPoint and Outlook; working knowledge of Excel, Project, Visio, and SharePoint.
- Excellent command of English language and proficiency in Associated Press Style guidelines.

Other

Required:
- Excellent verbal and written communications skills
- Effective management skills – organization, planning, setting goals and objectives, time management
- Effective leadership skills
- Excellent interpersonal skills
- Excellent social skills
- Thorough appreciation of cultural diversity and sensitivity toward target populations

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 conduct and participate in meetings
- Must be able to travel on common carriers and adhere to Amerigroup’s travel policies

ermSM
]]>Sun, 02 Jun 2013 08:00:00 GMThttp://www.amerigroup-jobs.com/job/Virginia-Beach-Writer-Comm-Svcs-Job-VA-23450/2581110/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSShttp://www.amerigroup-jobs.com/job/Virginia-Beach-Writer-Comm-Svcs-Job-VA-23450/2581110/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS
Job ID 2013-22777 # Positions 1
Location US-VA-Virginia Beach
Search Category Communications
Type Regular Full-Time (30+ hours) Posted Date 5/6/2013
Additional Locations ..

More information about this job:
Summary:

The Public Relations Specialist will provide support to a Communications team with various public relations and communication projects and tasks. This position will work collaboratively with senior leadership on the Communications team, Health Plan leadership, Consultants, Vendors and relevant business owners to promote “Real Stories,” various Company activities, Amerigroup Foundation events, corporate events and conferences across the health plans to enhance the Company’s image and brand. The Public Relations Specialist will implement the social media strategy, coordinating with department management to ensure its effectiveness and encouraging adoption of relevant social media techniques in the culture.

Responsibilities:

1. Collaborates with writers, web designers, graphic artists, developers and Subject Matter Experts (SMEs) to develop written material, collaterals, press releases, talking points, scripts, web content copy and other relevant materials to promote and inform the public and press of Company campaigns and events.

2. Creates communications strategy for prioritized health plan markets and business development markets.

3. Ownership for leveraging and highlighting Public Relations opportunities for the AGP Foundation—create corporate and health plan media advisories and press releases for each event.

4. Seeks opportunities to promote Amerigroup in our current and business development markets.

5. In collaboration with the department leaders and the external public relations company, will help manage the Amerigroup Speaker’s Bureau.

6. Assists the Public Relations team plan and conduct speaking engagements and other formal presentations with the general public, media, community groups, and employees. Research subject matter; provide support on key message development; and coordinate the development of audio and visual materials if required. Ensure communications are tailored to the audience.

7. Maintains working relationship with national, local and specialty media contacts germane to the health care industry, national business and other key outlets.

8. Strategizes and develops plan with contracted Public Relations firm, in pitching, booking, and coordinating interviews for Company spokesperson(s), executives and SMEs.

9. Supports the Company’s social media platform, internal framework, process and outreach. Providing daily management of all social properties including but not limited to Twitter, Facebook, LinkedIn and YouTube accounts based on company objectives and support for market messaging as well as other critical areas.

10. Perform other duties as assigned or requested.

Qualifications:

EDUCATION AND EXPERIENCE

Education

Required:
- Bachelor’s degree in English, Journalism, Communications, Public Relations or other related experience in lieu of degree(s).

Preferred:
- Accredited in Public Relations (APR) designation or Accredited Business Communicator (ABC) designation.

Years and Type of Experience Required:

Required:
- Minimum three years relevant work experience.

Preferred:
- Minimum five years of related media relations experience; Health care industry and/or political experience a plus.

Language Skills

Required:
- English

Functional Competencies
- Proficient in Associated Press style writing standards.
- Ability to work independently, as a team member and collaborate with associates at all levels.
- Demonstrate sound decision-making, problem-solving, good judgment, research and presentation skills.
- Demonstrate effective verbal, written and broad communications experience with depth in media relations, issues management, and crisis communication.
- Maintain knowledge of government regulations and emerging web technology to ensure regulatory compliance.
- A creative and strategic thinker with broad public affairs and public relations experience.
- Demonstrate an enthusiasm for motivating people.
- Demonstrate analytical and persuasion/negotiation skills.
- Experience in strategic approach to communication and program development.

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.


]]>Tue, 04 Jun 2013 07:59:00 GMThttp://www.amerigroup-jobs.com/job/Virginia-Beach-Public-Relations-Specialist-Job-VA-23450/2582910/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSShttp://www.amerigroup-jobs.com/job/Virginia-Beach-Public-Relations-Specialist-Job-VA-23450/2582910/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS
Job ID 2013-22834 # Positions 1
Location US-NATIONWIDE
Search Category Legal
Type Regular Full-Time (30+ hours) Posted Date 5/13/2013
Additional Locations ..

More information about this job:
Summary:

The position is responsible for the regulatory compliance activities of AMERIGROUP’s Medicare Advantage(“MA”), Special Needs Plan (“SNP”), and Part D Prescription Drug (“PD”) product offerings The Compliance Analyst focuses on AMERIGROUP and its delegated vendor’s, first tier, and downstream related entities compliance with the regulatory/contractual obligations of the Centers for Medicare and Medicaid Services (“CMS”) and multiple state regulatory bodies, as well as oversight of the MAPD and SNP product requirements and deliverables.

Responsibilities:

1. Support the oversight of the federal and state regulatory compliance programs and activities for AMERIGROUP’s SNP and MA-PD products:
- Provide management with information for strategic planning.
- AMERIGROUP liaison with CMS and applicable state agencies, serving as “account manager.”
- Maintain productive working relationships with key regulators charged with AMERIGROUP contract administration that leads to a collaboration benefiting company operations and activity.
- Subject matter expert on Medicare Advantage and Part D requirements and programs.

2. Assess, communicate and ensure associate understanding of federal regulations, legislation and CMS Operational Manuals and Memorandums that impact business activity and operations.

3. Maintain resource tools identifying SNP and MA-PD requirements for internal education, and compliance assessments.

4. Conduct onsite and/or desktop audits of all delegated vendors and ensure compliance with training requirements for all applicable contractors.

5. Manage schedule of both internal areas and delegated vendors, ensure all corrective actions are implemented, and ensure all audits are conducted on time and thoroughly.

6. Participate in AMERIGROUP and vendor preparations for multiple SNP and MA-PD performance assessments, CMS audits, and Program Integrity Audits:
- Assist in preparing AMERIGROUP and vendor operational leads for targeted audit activity.
- Coordinate and organize desk review submissions and on-site audit materials.
- Participate in on-site assessment and audit activity.
- Facilitate development of corrective action plans (“CAPs”) and oversee CAP implementation.
- Interact with audit and enforcement agencies to correct deficiencies and minimize CMS administrative actions and sanction activity. Manage submissions of regulatory deliverables and monitor CMS management reports.

7. Responsible for the review and submission of CMS Part C and D reporting to ensure compliance with CMS requirements.

8. Manage regulatory filings and approvals of marketing/advertising materials, member correspondence and outreach programs through CMS HPMS system.
- Review collateral materials via Collateral Material Approval Process;
- Negotiate approvals by CMS and state agency liaisons.

9. Participate in SNP and MA-PD product expansion and new market activities via project management of regulatory document preparation, submission and federal/state approvals.
- Define regulatory requirements and maintain project plan and document tracking system.
- Identify/attain agreement on business owner accountability for deliverables.
- Guide project team members to ensure project deliverables are met, disconnects identified and resolutions achieved.
- Department implementation lead. 10. Other duties as assigned.

Qualifications:

EDUCATION AND EXPERIENCE

Education

Required:
- High School Diploma with 3 years relevant work experience.

Preferred:
- Bachelor’s Degree.

Years and Type of Experience Required:

Required:
- Minimum of 3 years experience working in regulatory operations of a Medicare Advantage (Medicare+Choice) plan
- Knowledge of federal HMO and Medicare Managed care regulations

Specific Technical Skills

Required:
- Intermediate level Microsoft Office Suite skills.
- Specifically Word and Excel.

Other:

Required:
- Strong analytical and organizational skills.
- Strong verbal and written communication skills.
- Ability to analyze, interpret, and summarize contracts, regulations, policies/procedures, reports and legal documents.
- Ability to respond to questions/concern from internal customers and regulatory agencies present company position in understandable and unambiguous manner.
- Ability to identify root cause, recommend options and implement/negotiate appropriate solutions.
- Ability to effectively set priorities and meet commitments.
- Ability to work under pressure and within strict time frames.
- Comfortable interfacing at all levels of the organization.
- Appreciation of cultural diversity and sensitivity towards target population.

PHYSICAL REQUIREMENTS
- Must be able to operate a computer and a telephone.
- Must be able to access/operate filing systems.
- Must be able to conduct, facilitate, and actively participate in meetings.
- Periodic travel required - must be able to travel on common carrier.

ermCorp
]]>Tue, 11 Jun 2013 07:59:00 GMThttp://www.amerigroup-jobs.com/job/Compliance-Analyst-Medicare-%28position-located-in-Virginia-Beach%29-Job/2594751/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSShttp://www.amerigroup-jobs.com/job/Compliance-Analyst-Medicare-%28position-located-in-Virginia-Beach%29-Job/2594751/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS
Job ID 2013-22967 # Positions 1
Location US-VA-Virginia Beach
Search Category Information Technology
Type Regular Full-Time (30+ hours) Posted Date 6/10/2013
Additional Locations ..

More information about this job:
Summary:

Functions as a recognized expert; leads the identification, improvement planning and implementation of business process improvements and work to advance Amerigroup’s strategic imperatives. Leads process improvement initiatives and is responsible for improving Amerigroup business processes through application and disciplined use of best practices, process metrics, process mapping, incremental process improvement methods such as Six Sigma and Work Out^TM and also lead full process re-engineering initiatives. Leads the discussion of process alternatives in order to arrive at best practices. Coordinates the development of process documentation, process staffing models and education for identified projects. Builds strong working relationships with Corporate and Plan senior management and support areas to assist in meeting the goals of the organization. Responsible for identifying and prioritizing opportunities for improvement in the areas of efficiency and effectiveness. Focus is on process analysis and re-engineering, with an understanding of technical problems and solutions as they relate to the current and future business environment. Involved in developing, modifying and executing company policies that affect immediate operations and may also have company-wide effect.

The incumbent will be responsible for various projects and initiatives such as but not limited to:
- Overseeing the Budget, and partnering with Finance
- Assisting the Medicaid CIO in providing direction to area/management team
- Enable and ensure execution on strategy
- Manage and drive the resource staffing plan
- Vendor Management / Contract Administration for SOW for labor/SW / HW in conjunction with CIO Office
- Partner with HR and IT Leaders to assist with talent development and succession planning
- Working/driving processes in organization including the Medicaid IT Project Management office
- Partner with HR/Legal/IT COS Office/Communications
- Driving Hiring/Terminations/Reductions in Force
- Overseeing SOW process/compliance
- Overseeing/delivering monthly reporting / metrics to the WLP CIO Office
- Communications for area
- Audit/Compliance SPOC
- Overseeing Medicaid EA (Enterprise Architecture) and liaison to WLP CTO office
- Ownership of Corporate Initiatives
- Ownership of SOW/Vendor Mgmt Liaison to WLP CIO office

Responsibilities:

1. Lead business process improvement initiatives and facilitates collaborative efforts to arrive at best practices.

2. Plan, perform and implement the design, implementation planning, implementation and maintaining of business processes and improvement initiatives. Works on issues where analysis of situations or data requires an in-depth knowledge of organizational objectives.

3. Lead the delivery of significant, quantifiable, annualized cost savings or customer satisfaction improvements.

4. Measure current organizational and process performance using a variety of qualitative and quantitative techniques including: one-on-one user interviews, surveys, observational studies and statistical analysis.

5. Provide business and technical expertise concerning business.

6. Creates process change by integrating new processes with existing ones and communicating these changes to impacted Business Systems teams.

7. Structure and conduct best practice research, process analysis, benchmarking and performance baselines measurement activities.

8. Work to ensure appropriate key operational indicators are in place for monitoring and analysis.

9. Maintain dashboard of key operational indicators, identifies and reports issues to management.

10. Identify opportunities for operational excellence and works to create seamless processes.

11. Work to resolve operational issues to include all functional disciplines within Amerigroup.

12. Maintain awareness of initiatives to ensure priority alignment and promotes communication and collaboration.

13. Recognize and utilize appropriate channels for communication, encourages two-way communication with Plan and Corporate staff to participate in creative program development resulting in improved efficiency and enhanced job performance.

14. Partner and support management across the company on assigned projects ensuring company goals and initiatives are met. May act as project manager in some cases.

15. Perform other duties as assigned/requested.

Qualifications:

EDUCATION AND EXPERIENCE

Education

Required:
- Bachelor’s Degree or equivalent experience in Business, Health Care or related field.

Preferred:
- Master’s Degree.

Years and Type of Experience Required:

Required:
- 10 years relevant work experience and at least 5 years of leadership/management including project management experience in a medium to large size business environment.
- Minimum 3 years of demonstrated experience in data assimilation & analysis.

Preferred:
- Background in Healthcare or IT.
- Quality training a plus.

Specific Technical Skills

Required:
- Experience with change management.
- Experience with conflict resolution/mediation.
- Demonstrate mastery of process improvement methodology (i.e., Six Sigma certification and Work Out^TM) in appropriate timeframe as directed by management.
- Demonstrates high levels of flexibility by managing projects based on strategic priorities.
- Requires highest level understanding of organization's business systems and industry requirements.

Certifications or Licensures

Preferred:
- Six Sigma Black Belt certification.
- Project Management Professional (PMP^TM) certification.

Other:

Required:
- Excellent analytical, organizational, problem-solving, and communication skills.
- Ability to demonstrate political sensitivity and to work effectively with senior level management as well as with multi-disciplinary teams across department lines.
- Able to maintain strategic vision; ensures scope stays in alignment with corporate strategy.
- Demonstrated leadership in healthcare operations including root cause identification.
- Strong facilitation skills.
- Excellent interpersonal skills with the ability to promote team development.
- Strong leadership, coaching, and staff development skills.
- Strong knowledge of data management and interpretation.

SCOPE INFORMATION

# Direct Reports: 2-4

# Indirect Reports: Varies, depending upon project.

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 attend and participate in meetings.
- Must be able to travel as needed (approximately 25%) and adhere to Amerigroup travel policies and procedures.

ermIT
]]>Wed, 29 May 2013 05:00:00 GMThttp://www.amerigroup-jobs.com/job/Virginia-Beach-AVP-Business-Improvement-IT-Chief-of-Staff-%28Telecommuters-Accepted%29-Job-VA-23450/2627213/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSShttp://www.amerigroup-jobs.com/job/Virginia-Beach-AVP-Business-Improvement-IT-Chief-of-Staff-%28Telecommuters-Accepted%29-Job-VA-23450/2627213/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS
Job ID 2013-22811 # Positions 16
Location US-VA-Virginia Beach
Search Category Nursing
Type Regular Full-Time (30+ hours) Posted Date 6/11/2013
Additional Locations ..

More information about this job:
Summary:

Under general supervision, licensed clinician responsible for day to day telephonic medical management and pre-authorization activities. Manages member care ensuring essential, effective, appropriate and coordinated behavioral and physical health and social services. Acts as a member advocate, seeking and coordinating solutions to member health care needs.

This position will be located in our National Call Center in Virginia Beach, VA. All associates will need to have a current LPN or RN license in the State of Virginia.

Responsibilities:

1. Provides telephonic advice and education on the pre-authorization process to members.

2. Maintains and utilizes working relationships with and knowledge of referral sources and community resources.

3. Adheres to all company and state policies, accreditation standards and regulatory guidelines.

4. Utilizes the application of medical management criteria or other company designated criteria.

5. Acts as a clinical resource to other internal departments.

6. Communicates to assigned supervisor or leads all cases needing a higher level of intervention.

7. Documents all pre-certifications and authorization requests as well as all member encounters utilizing the appropriate systems and resources.

8. Utilizes leadership skills for non-clinical team members.

9. Collaboratively works with other departments.

10. Participates in Quality Improvement processes.

11. Performs other duties as assigned.

Qualifications:

EDUCATION AND EXPERIENCE

Education

Required:
- Nursing Diploma, or
- Associate’s Degree in related Health/Nursing Field

Preferred:
- Bachelor’s or Master’s Degree in related Health/Nursing Field

Years and Type of Experience Required:

Required:
- 2 Years experience as a licensed RN
- or 3 years experience as a licensed LPN/LVN in the Health Care or Managed Care Industry

Preferred:
- Experience working on the community level and with community agencies.

Certifications or Licensures

Required:
- Active licensed LVN or LPN

Preferred:
- Active licensed RN

Language Skills

Required:
- English

Preferred:

Technical Competencies

Computer Hardware, Software, and Applications/ Office Equipment-Intermediate
- Ability to use software and hardware of a computer to complete certain simple to moderately-complex tasks. Skills 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 and keyboard. Use of internet. Ability to review and draft correspondence in email system and word processing systems. Ability to use spreadsheets to review, organize and edit data.
- Ability to use software to conduct data analysis, reporting and sharing of information to solve problems.

Communication Skills

Verbal, Written and Call Handling
- Ability to use proper language, grammar and style in the preparation of verbal and written messages to convey a clear, concise, friendly and appropriate message to business partners and customers.
- Skills to properly handle a telephone inquiry into the contact center. Properly greet the customer and provide information based on purpose for the call and script requirements.
- Ability to prepare, edit and convey a variety of messages including presentations, training materials and updates. Ability to handle escalated issues to diffuse concerns through verbal and written messages. Heath Care Industry terminology.
- Ability to understand basic health care industry terms. Ability to understand how an insurance claim works and use the explanation of benefits to explain details to providers.

Read, Interpret and Apply information
- Ability to read and comprehend information and provide detailed explanation to the business partner or customer that is accurate and appropriate.
- Ability to research information using available resources and determine where gaps in information exist to seek other sources.

Medical Terminology and Anatomy
- Understand medical terminology to review clinical certifications. Hands on clinical skills to understand the workings of the human body to review and apply clinical criteria to certifications.

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.

ermHO
]]>Tue, 11 Jun 2013 05:00:00 GMThttp://www.amerigroup-jobs.com/job/Virginia-Beach-Nurse-Coordinator-NCC-Job-VA-23450/2656536/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSShttp://www.amerigroup-jobs.com/job/Virginia-Beach-Nurse-Coordinator-NCC-Job-VA-23450/2656536/?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.

This position will sit in our Virginia Beach office.

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
]]>Sat, 08 Jun 2013 07:59:00 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 2013-22820 # 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
]]>Sat, 08 Jun 2013 07:59:00 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