http://www.amerigroup-jobs.com/feeds/director-human-resources-jobs/ Custom RSS Feed for director-human-resources-jobs Tue, 21 May 2013 11:47:02 GMT en-us /sites/amerigroup/images/banner.gif http://www.amerigroup-jobs.com/feeds/director-human-resources-jobs/ 720
Job ID 2013-22540 # Positions 1
Location US-VA-Virginia Beach
Search Category Human Resources
Type Regular Full-Time (30+ hours) Posted Date 4/10/2013
Additional Locations ..

More information about this job:
Summary:

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

Responsibilities:

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

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

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

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

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

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

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

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

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

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

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

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

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

14. Other duties as assigned.

Qualifications:

Education

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

Preferred: Master’s degree

Years and Type of Experience Required:

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

Specific Technical Skills

Required: Excellent computer skills including Microsoft Office Suite

Preferred: Experience working with PeopleSoft

Certifications or Licensures

Preferred: SPHR

Other:

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

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

Varies Budgetary $ Responsibility:

Varies based on assignment

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

ermCorp
]]>Thu, 09 May 2013 02:59:00 GMThttp://www.amerigroup-jobs.com/job/Virginia-Beach-Director-Human-Resources-Job-VA-23450/2540206/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSShttp://www.amerigroup-jobs.com/job/Virginia-Beach-Director-Human-Resources-Job-VA-23450/2540206/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS
Job ID 2013-22715 # Positions 1
Location US-VA-Norfolk
Search Category Pharmacy
Type Regular Full-Time (30+ hours) Posted Date 4/30/2013
Additional Locations ..

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
]]>Wed, 01 May 2013 00:00:00 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 2013-22606 # Positions 1
Location US-NY-Brooklyn
US-NY-New York
Search Category Health Care Operations
Type Regular Full-Time (30+ hours) Posted Date 4/17/2013
Additional Locations US-NY-New York

More information about this job:
Summary:

Responsible for the overall administration and management of the Enrollment Operations Department, including planning, providing strategic leadership, coordinating information and establishing departmental operating practices. Responsible for the overall direction and guidance of the Enrollment Operations Department ensuring the quality of the Enrollment database and efficient operation of the department for the service of the membership.

Responsibilities:

1. Oversees department to meet or exceed departmental goals and staying within budget, including productivity metrics, quality and timeliness standards as defined by department guidelines.

2. Develops performance-based metrics to facilitate measurement of staff productivity, to continually increase performance.

3. Develops and document process flows and policies for the department to support company goals and objectives. Ensures processes are in line with state and federal contracts and the strategic vision of the organization.

4. Determines root causes of contractual deficiencies, and develops documentation to facilitation remediation.

5. Performs quality assurance functions to ensure Sarbanes-Oxley (SOX) controls are in place and valid. Initiates action plans to resolve issues, and implements procedures in concert with contract requirements and federal and state laws.

6. Serves as primary department liaison for Enrollment activities in state, federal and organizational audits.

7. Reviews and responds to contract proposals and oversees the implementation of new business for the Enrollment department.

8. Performs project management functions in achieving the timely completion of Enrollment deliverables.

9. Works collaboratively with inter-departmental work groups on key organizational initiatives and implementations.

10. Manages the recruitment, interview, and hiring process for potential candidates. Responsible for performance management of associates on a recurring basis to include reviews, corrective action, and recognition programs. Ensures training and development to staff; mentors Managers; provides performance coaching and feedback.

11. Performs other duties as assigned.

Qualifications:

EDUCATION AND EXPERIENCE

Education

Required:
- Bachelor’s Degree in Information Systems, Health Care Management, Business or equivalent experience

Years and Type of Experience Required:

Required:
- Seven years of enrollment experience in a healthcare insurance company, with at least three years of leadership/management experience.

Preferred:
- Project Management experience.

Language Skills

Required:
- English

Technical Competencies Computer Skills and Office Equipment - Advanced
- Ability to use software and hardware of a computer to complete certain moderate to 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. Ability to use of complex applications of software to analyze and solve business problems. Spreadsheet Utilization and Management
- Advanced: Expert level of proficiency 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. Ability to create spreadsheets in spreadsheets.

Industry Knowledge & Familiarity - Basic
- General understanding of the healthcare industry including who are providers (hospitals phy ofc, ancil), who are payors (insurance companies) and how the industry works.
- General understanding of the claims process.
- More specific knowledge around reimbursement methodology, fee schedules and related terminology, e.g. per case, per diem, DRG, % of charges, etc. 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), etc.

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

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: 3-5

# Indirect Reports: 40 - 60

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.

ermHO
]]>Thu, 16 May 2013 02:59:00 GMThttp://www.amerigroup-jobs.com/job/Brooklyn-Director-Enrollment-Job-NY-11201/2551824/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSShttp://www.amerigroup-jobs.com/job/Brooklyn-Director-Enrollment-Job-NY-11201/2551824/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS
Job ID 2013-22816 # Positions 1
Location US-VA-Virginia Beach
Search Category Customer Service
Type Regular Full-Time (30+ hours) Posted Date 5/10/2013
Additional Locations ..

More information about this job:
Summary:

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

Responsibilities:

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

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

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

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

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

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

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

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

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

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

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

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

13. Performs other duties as assigned.

Qualifications:

EDUCATION AND EXPERIENCE

Education

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

Years and Type of Experience Required:

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

Language Skills

Required:
- English

Technical Competencies

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

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

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

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

Communication Skills

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

Behavioral Competencies

Strategic Leadership

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

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

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

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

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

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

SCOPE INFORMATION

# Direct Reports: 4

# Indirect Reports: 50-60

Budgetary $ Responsibility: $4-10 million

PHYSICAL REQUIREMENTS

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

ermCS
]]>Fri, 10 May 2013 00:00:00 GMThttp://www.amerigroup-jobs.com/job/Virginia-Beach-Director-Cost-Containment-Job-VA-23450/2592118/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSShttp://www.amerigroup-jobs.com/job/Virginia-Beach-Director-Cost-Containment-Job-VA-23450/2592118/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS
Job ID 2013-21877 # Positions 1
Location US-NM-Albuquerque
Search Category Nursing
Type Regular Full-Time (30+ hours) Posted Date 5/15/2013
Additional Locations ..

More information about this job:
Summary:

Responsible for evaluating the necessity, appropriateness and efficiency of the use of medical services procedures and facilities. Licensed RN Responsible for clinical review of all acute and sub acute services for appropriateness based on medical criteria, the management of healthcare resources necessary and appropriate for achievement of desired acute and sub acute outcomes, and the coordination of alternative levels of care for members. Serves as a patient advocate, seeking and coordinating creative solutions to patients’ health care needs without compromising quality outcomes.

Responsibilities:

1. Performs on-site and/or telephonic review of acute and sub acute services.

2. Predicts and plans for patient’s needs from pre-admission, through acute and sub acute care and post-discharge, in collaboration with the member.

3. Utilizes pre-approved criteria and guidelines to validate medical necessity of continued stay and appropriateness of treatment and discharge planning.

4. Acts in conjunction with the appropriate manager(s) on a daily basis to assess the inpatient census for appropriate alternative health care service needs.

5. Coordinates with appropriate discharge planning team members, facility utilization management department, physicians and members to coordinate timely discharges.

6. Participates in Quality Improvement Process; tracks and reports trends of inappropriate utilization of resources to the Medical Director; identifies and reports any quality or utilization issues to the Medical Director.

7. Acts in conjunction with the clinical team related to discharge planning (e.g., home care, hospice care, rehabilitation care, special program care, transitional care, occupational therapy, speech, respiratory and physical therapy), durable equipment and disposable supplies.

8. Documents all activities in the appropriate system(s) on a timely basis.

9. Participates in rounds with the Medical Director.

10. Reviews health plan appeal items for concurrent and retrospective reviews as required and requested.

11. Monitors and facilities appropriate utilization of resources using appropriate clinical criteria.

12. Participates in a multi-disciplinary clinical team to achieve positive member outcomes; Functions as a resource to the clinical team regarding approved criteria, practice guidelines and alternative treatment options.

13. Other duties as requested or assigned.

Qualifications:

EDUCATION AND EXPERIENCE

Education

Required:
- Nursing Diploma.
- Associate’s Degree in related Health/Nursing field.

Preferred:
- Bachelor’s Degree in related Health/Nursing field.

Years and Type of Experience Required:

Required:
- Minimum of two years of utilization management or hospital/acute care experience.

Preferred:
- Minimum of three years experience in health care, case management, discharge planning, utilization management, or behavioral health.
- Experience working on the community level and with community agencies.

Certifications or Licensures

Required:
- RN
- Must possess a valid driver’s license and access to a motor vehicle.

Preferred:
- Certified Professional Healthcare Management

Language Skills

Required:
- English

Preferred:
- Bilingual

Functional Competencies
- Proficient in the use of Microsoft Office tools. Able to use basic office equipment such as telephone, fax machine and copy machine. Use of Internet and working knowledge in a windows environment to include navigation skills using a mouse, keyboard and number pad Ability to review and draft correspondence in email system and word processing systems.
- Experience working with utilization management data systems.

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, 16 May 2013 02:59:00 GMThttp://www.amerigroup-jobs.com/job/Albuquerque-Utilization-Manager-RN-Albuquerque%2C-New-Mexico-Job-NM-87101/2401758/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSShttp://www.amerigroup-jobs.com/job/Albuquerque-Utilization-Manager-RN-Albuquerque%2C-New-Mexico-Job-NM-87101/2401758/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS
Job ID 2013-22056 # Positions 2
Location US-TN-Nashville
Search Category Nursing
Type Regular Full-Time (30+ hours) Posted Date 2/19/2013
Additional Locations ..

More information about this job:
Summary:

Responsible for evaluating the necessity, appropriateness and efficiency of the use of medical services procedures and facilities. Responsible for clinical review of all acute and sub acute services for appropriateness based on medical criteria, the management of healthcare resources necessary and appropriate for achievement of desired acute and sub acute outcomes, and the coordination of alternative levels of care for members. Serves as a patient advocate, seeking and coordinating creative solutions to patients’ health care needs without compromising quality outcomes.

Responsibilities:

1. Performs on-site and/or telephonic review of acute and sub acute services.

2. Predicts and plans for patient’s needs from pre-admission, through acute and sub acute care and post-discharge, in collaboration with the member.

3. Utilizes pre-approved criteria and guidelines to validate medical necessity of continued stay and appropriateness of treatment and discharge planning.

4. Acts in conjunction with the appropriate manager(s) on a daily basis to assess the inpatient census for appropriate alternative health care service needs.

5. Coordinates with appropriate discharge planning team members, facility utilization management department, physicians and members to coordinate timely discharges.

6. Participates in Quality Improvement Process; tracks and reports trends of inappropriate utilization of resources to the Medical Director; identifies and reports any quality or utilization issues to the Medical Director.

7. Acts in conjunction with the clinical team related to discharge planning (e.g., home care, hospice care, rehabilitation care, special program care, transitional care, occupational therapy, speech, respiratory and physical therapy), durable equipment and disposable supplies.

8. Documents all activities in the appropriate system(s) on a timely basis.

9. Participates in rounds with the Medical Director.

10. Reviews health plan appeal items for concurrent and retrospective reviews as required and requested.

11. Monitors and facilities appropriate utilization of resources using appropriate clinical criteria.

12. Participates in a multi-disciplinary clinical team to achieve positive member outcomes; Functions as a resource to the clinical team regarding approved criteria, practice guidelines and alternative treatment options.

13. Other duties as requested or assigned.

Qualifications:

EDUCATION AND EXPERIENCE

Education

Required:
- Nursing Diploma.
- Associate’s Degree in related Health/Nursing field.

Preferred:
- Bachelor’s Degree in related Health/Nursing field.

Years and Type of Experience Required:

Required:
- Minimum of two years of utilization management or hospital/acute care experience.

Preferred:
- Minimum of three years experience in health care, case management, discharge planning, utilization management, or behavioral health.
- Experience working on the community level and with community agencies.

Certifications or Licensures

Required:
- RN
- Must possess a valid driver’s license and access to a motor vehicle.

Preferred:
- Certified Professional Healthcare Management

Language Skills

Required:
- English

Preferred:
- Bilingual

Functional Competencies
- Proficient in the use of Microsoft Office tools. Able to use basic office equipment such as telephone, fax machine and copy machine. Use of Internet and working knowledge in a windows environment to include navigation skills using a mouse, keyboard and number pad Ability to review and draft correspondence in email system and word processing systems.
- Experience working with utilization management data systems.

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
]]>Fri, 17 May 2013 02:59:00 GMThttp://www.amerigroup-jobs.com/job/Nashville-Utilization-Manager-RN-Job-TN-37201/2437130/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSShttp://www.amerigroup-jobs.com/job/Nashville-Utilization-Manager-RN-Job-TN-37201/2437130/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS
Job ID 2013-22066 # Positions 1
Location US-TN-Nashville
Search Category Nursing
Type Regular Full-Time (30+ hours) Posted Date 5/6/2013
Additional Locations ..

More information about this job:
Summary:

Responsible for evaluating the necessity, appropriateness and efficiency of the use of medical services procedures and facilities. Responsible for clinical review of all acute and sub acute services for appropriateness based on medical criteria, the management of healthcare resources necessary and appropriate for achievement of desired acute and sub acute outcomes, and the coordination of alternative levels of care for members. Serves as a patient advocate, seeking and coordinating creative solutions to patients’ health care needs without compromising quality outcomes.

Responsibilities:

1. Performs on-site and/or telephonic review of acute and sub acute services.

2. Predicts and plans for patient’s needs from pre-admission, through acute and sub acute care and post-discharge, in collaboration with the member.

3. Utilizes pre-approved criteria and guidelines to validate medical necessity of continued stay and appropriateness of treatment and discharge planning.

4. Acts in conjunction with the appropriate manager(s) on a daily basis to assess the inpatient census for appropriate alternative health care service needs.

5. Coordinates with appropriate discharge planning team members, facility utilization management department, physicians and members to coordinate timely discharges.

6. Participates in Quality Improvement Process; tracks and reports trends of inappropriate utilization of resources to the Medical Director; identifies and reports any quality or utilization issues to the Medical Director.

7. Acts in conjunction with the clinical team related to discharge planning (e.g., home care, hospice care, rehabilitation care, special program care, transitional care, occupational therapy, speech, respiratory and physical therapy), durable equipment and disposable supplies.

8. Documents all activities in the appropriate system(s) on a timely basis.

9. Participates in rounds with the Medical Director.

10. Reviews health plan appeal items for concurrent and retrospective reviews as required and requested.

11. Monitors and facilities appropriate utilization of resources using appropriate clinical criteria.

12. Participates in a multi-disciplinary clinical team to achieve positive member outcomes; Functions as a resource to the clinical team regarding approved criteria, practice guidelines and alternative treatment options.

13. Other duties as requested or assigned.

Qualifications:

EDUCATION AND EXPERIENCE

Education

Required:
- Nursing Diploma.
- Associate’s Degree in related Health/Nursing field.

Preferred:
- Bachelor’s Degree in related Health/Nursing field.

Years and Type of Experience Required:

Required:
- Minimum of two years of utilization management or hospital/acute care experience.

Preferred:
- Minimum of three years experience in health care, case management, discharge planning, utilization management, or behavioral health.
- Experience working on the community level and with community agencies.

Certifications or Licensures

Required:
- RN
- Must possess a valid driver’s license and access to a motor vehicle.

Preferred:
- Certified Professional Healthcare Management

Language Skills

Required:
- English

Preferred:
- Bilingual

Functional Competencies
- Proficient in the use of Microsoft Office tools. Able to use basic office equipment such as telephone, fax machine and copy machine. Use of Internet and working knowledge in a windows environment to include navigation skills using a mouse, keyboard and number pad Ability to review and draft correspondence in email system and word processing systems.
- Experience working with utilization management data systems.

PHYSICAL REQUIREMENTS

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

ermHO
]]>Sat, 18 May 2013 05:31:00 GMThttp://www.amerigroup-jobs.com/job/Nashville-Utilization-Manager-RN-Job-TN-37201/2439652/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSShttp://www.amerigroup-jobs.com/job/Nashville-Utilization-Manager-RN-Job-TN-37201/2439652/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS
Job ID 2013-21793 # Positions 1
Location US-NY-New York
Search Category Nursing
Type Regular Full-Time (30+ hours) Posted Date 4/17/2013
Additional Locations ..

More information about this job:
Summary:

Responsible for evaluating the necessity, appropriateness and efficiency of the use of medical services procedures and facilities. Responsible for clinical review of all acute and sub acute services for appropriateness based on medical criteria, the management of healthcare resources necessary and appropriate for achievement of desired acute and sub acute outcomes, and the coordination of alternative levels of care for members. Serves as a patient advocate, seeking and coordinating creative solutions to patients’ health care needs without compromising quality outcomes.

Responsibilities:

1. Performs on-site and/or telephonic review of acute and sub acute services.

2. Predicts and plans for patient’s needs from pre-admission, through acute and sub acute care and post-discharge, in collaboration with the member.

3. Utilizes pre-approved criteria and guidelines to validate medical necessity of continued stay and appropriateness of treatment and discharge planning.

4. Acts in conjunction with the appropriate manager(s) on a daily basis to assess the inpatient census for appropriate alternative health care service needs.

5. Coordinates with appropriate discharge planning team members, facility utilization management department, physicians and members to coordinate timely discharges.

6. Participates in Quality Improvement Process; tracks and reports trends of inappropriate utilization of resources to the Medical Director; identifies and reports any quality or utilization issues to the Medical Director.

7. Acts in conjunction with the clinical team related to discharge planning (e.g., home care, hospice care, rehabilitation care, special program care, transitional care, occupational therapy, speech, respiratory and physical therapy), durable equipment and disposable supplies.

8. Documents all activities in the appropriate system(s) on a timely basis.

9. Participates in rounds with the Medical Director.

10. Reviews health plan appeal items for concurrent and retrospective reviews as required and requested.

11. Monitors and facilities appropriate utilization of resources using appropriate clinical criteria.

12. Participates in a multi-disciplinary clinical team to achieve positive member outcomes; Functions as a resource to the clinical team regarding approved criteria, practice guidelines and alternative treatment options.

13. Other duties as requested or assigned.

Qualifications:

EDUCATION AND EXPERIENCE

Education

Required:
- Nursing Diploma.
- Associate’s Degree in related Health/Nursing field.

Preferred:
- Bachelor’s Degree in related Health/Nursing field.

Years and Type of Experience Required:

Required:
- Minimum of two years of utilization management or hospital/acute care experience.

Preferred:
- Minimum of three years experience in health care, case management, discharge planning, utilization management, or behavioral health.
- Experience working on the community level and with community agencies.

Certifications or Licensures

Required:
- RN
- Must possess a valid driver’s license and access to a motor vehicle.

Preferred:
- Certified Professional Healthcare Management

Language Skills

Required:
- English

Preferred:
- Bilingual

Functional Competencies
- Proficient in the use of Microsoft Office tools. Able to use basic office equipment such as telephone, fax machine and copy machine. Use of Internet and working knowledge in a windows environment to include navigation skills using a mouse, keyboard and number pad Ability to review and draft correspondence in email system and word processing systems.
- Experience working with utilization management data systems.

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, 16 May 2013 02:59:00 GMThttp://www.amerigroup-jobs.com/job/New-York-Utilization-Manager-RN-Job-NY/2551823/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSShttp://www.amerigroup-jobs.com/job/New-York-Utilization-Manager-RN-Job-NY/2551823/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS
Job ID 2013-22800 # Positions 1
Location US-NJ-Iselin
Search Category Nursing
Type Regular Full-Time (30+ hours) Posted Date 5/8/2013
Additional Locations ..

More information about this job:
Summary:

Responsible for evaluating the necessity, appropriateness and efficiency of the use of medical services procedures and facilities. Licensed RN Responsible for clinical review of all acute and sub acute services for appropriateness based on medical criteria, the management of healthcare resources necessary and appropriate for achievement of desired acute and sub acute outcomes, and the coordination of alternative levels of care for members. Serves as a patient advocate, seeking and coordinating creative solutions to patients’ health care needs without compromising quality outcomes.

Responsibilities:

1. Performs on-site and/or telephonic review of acute and sub acute services.

2. Predicts and plans for patient’s needs from pre-admission, through acute and sub acute care and post-discharge, in collaboration with the member.

3. Utilizes pre-approved criteria and guidelines to validate medical necessity of continued stay and appropriateness of treatment and discharge planning.

4. Acts in conjunction with the appropriate manager(s) on a daily basis to assess the inpatient census for appropriate alternative health care service needs.

5. Coordinates with appropriate discharge planning team members, facility utilization management department, physicians and members to coordinate timely discharges.

6. Participates in Quality Improvement Process; tracks and reports trends of inappropriate utilization of resources to the Medical Director; identifies and reports any quality or utilization issues to the Medical Director.

7. Acts in conjunction with the clinical team related to discharge planning (e.g., home care, hospice care, rehabilitation care, special program care, transitional care, occupational therapy, speech, respiratory and physical therapy), durable equipment and disposable supplies.

8. Documents all activities in the appropriate system(s) on a timely basis.

9. Participates in rounds with the Medical Director.

10. Reviews health plan appeal items for concurrent and retrospective reviews as required and requested.

11. Monitors and facilities appropriate utilization of resources using appropriate clinical criteria.

12. Participates in a multi-disciplinary clinical team to achieve positive member outcomes; Functions as a resource to the clinical team regarding approved criteria, practice guidelines and alternative treatment options.

13. Other duties as requested or assigned.

Qualifications:

EDUCATION AND EXPERIENCE

Education

Required:
- Nursing Diploma.
- Associate’s Degree in related Health/Nursing field.

Preferred:
- Bachelor’s Degree in related Health/Nursing field.

Years and Type of Experience Required:

Required:
- Minimum of two years of utilization management or hospital/acute care experience.

Preferred:
- Minimum of three years experience in health care, case management, discharge planning, utilization management, or behavioral health.
- Experience working on the community level and with community agencies.

Certifications or Licensures

Required:
- RN
- Must possess a valid driver’s license and access to a motor vehicle.

Preferred:
- Certified Professional Healthcare Management

Language Skills

Required:
- English

Preferred:
- Bilingual

Functional Competencies
- Proficient in the use of Microsoft Office tools. Able to use basic office equipment such as telephone, fax machine and copy machine. Use of Internet and working knowledge in a windows environment to include navigation skills using a mouse, keyboard and number pad Ability to review and draft correspondence in email system and word processing systems.
- Experience working with utilization management data systems.

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, 08 May 2013 00:00:00 GMThttp://www.amerigroup-jobs.com/job/Iselin-Utilization-Manager-RN-Job-NJ-08830/2587595/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSShttp://www.amerigroup-jobs.com/job/Iselin-Utilization-Manager-RN-Job-NJ-08830/2587595/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS
Job ID 2013-22590 # Positions 1
Location US-KS-Overland Park
Search Category Nursing
Type Regular Full-Time (30+ hours) Posted Date 5/13/2013
Additional Locations ..

More information about this job:
Summary:

Responsible for evaluating the necessity, appropriateness and efficiency of the use of medical services procedures and facilities. Responsible for clinical review of all acute and sub acute services for appropriateness based on medical criteria, the management of healthcare resources necessary and appropriate for achievement of desired acute and sub acute outcomes, and the coordination of alternative levels of care for members. Serves as a patient advocate, seeking and coordinating creative solutions to patients’ health care needs without compromising quality outcomes.

Responsibilities:

1. Performs on-site and/or telephonic review of acute and sub acute services.

2. Predicts and plans for patient’s needs from pre-admission, through acute and sub acute care and post-discharge, in collaboration with the member.

3. Utilizes pre-approved criteria and guidelines to validate medical necessity of continued stay and appropriateness of treatment and discharge planning.

4. Acts in conjunction with the appropriate manager(s) on a daily basis to assess the inpatient census for appropriate alternative health care service needs.

5. Coordinates with appropriate discharge planning team members, facility utilization management department, physicians and members to coordinate timely discharges.

6. Participates in Quality Improvement Process; tracks and reports trends of inappropriate utilization of resources to the Medical Director; identifies and reports any quality or utilization issues to the Medical Director.

7. Acts in conjunction with the clinical team related to discharge planning (e.g., home care, hospice care, rehabilitation care, special program care, transitional care, occupational therapy, speech, respiratory and physical therapy), durable equipment and disposable supplies.

8. Documents all activities in the appropriate system(s) on a timely basis.

9. Participates in rounds with the Medical Director.

10. Reviews health plan appeal items for concurrent and retrospective reviews as required and requested.

11. Monitors and facilities appropriate utilization of resources using appropriate clinical criteria.

12. Participates in a multi-disciplinary clinical team to achieve positive member outcomes; Functions as a resource to the clinical team regarding approved criteria, practice guidelines and alternative treatment options.

13. Other duties as requested or assigned.

Qualifications:

EDUCATION AND EXPERIENCE

Education

Required:
- Nursing Diploma.
- Associate’s Degree in related Health/Nursing field.

Preferred:
- Bachelor’s Degree in related Health/Nursing field.

Years and Type of Experience Required:

Required:
- Minimum of two years of utilization management or hospital/acute care experience.

Preferred:
- Minimum of three years experience in health care, case management, discharge planning, utilization management, or behavioral health.
- Experience working on the community level and with community agencies.

Certifications or Licensures

Required:
- RN
- Must possess a valid driver’s license and access to a motor vehicle.

Preferred:
- Certified Professional Healthcare Management

Language Skills

Required:
- English

Preferred:
- Bilingual

Functional Competencies
- Proficient in the use of Microsoft Office tools. Able to use basic office equipment such as telephone, fax machine and copy machine. Use of Internet and working knowledge in a windows environment to include navigation skills using a mouse, keyboard and number pad Ability to review and draft correspondence in email system and word processing systems.
- Experience working with utilization management data systems.

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
]]>Mon, 13 May 2013 00:00:00 GMThttp://www.amerigroup-jobs.com/job/Overland-Park-RN%2C-Utilization-Manager-Outpatient-Job-KS-66062/2594748/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSShttp://www.amerigroup-jobs.com/job/Overland-Park-RN%2C-Utilization-Manager-Outpatient-Job-KS-66062/2594748/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS
Job ID 2013-22892 # Positions 1
Location US-NY-New York
Search Category Nursing
Type Regular Full-Time (30+ hours) Posted Date 5/16/2013
Additional Locations ..

More information about this job:
Summary:

Responsible for evaluating the necessity, appropriateness and efficiency of the use of medical services procedures and facilities. Responsible for clinical review of all acute and sub acute services for appropriateness based on medical criteria, the management of healthcare resources necessary and appropriate for achievement of desired acute and sub acute outcomes, and the coordination of alternative levels of care for members. Serves as a patient advocate, seeking and coordinating creative solutions to patients’ health care needs without compromising quality outcomes.

Responsibilities:

1. Performs on-site and/or telephonic review of acute and sub acute services.

2. Predicts and plans for patient’s needs from pre-admission, through acute and sub acute care and post-discharge, in collaboration with the member.

3. Utilizes pre-approved criteria and guidelines to validate medical necessity of continued stay and appropriateness of treatment and discharge planning.

4. Acts in conjunction with the appropriate manager(s) on a daily basis to assess the inpatient census for appropriate alternative health care service needs.

5. Coordinates with appropriate discharge planning team members, facility utilization management department, physicians and members to coordinate timely discharges.

6. Participates in Quality Improvement Process; tracks and reports trends of inappropriate utilization of resources to the Medical Director; identifies and reports any quality or utilization issues to the Medical Director.

7. Acts in conjunction with the clinical team related to discharge planning (e.g., home care, hospice care, rehabilitation care, special program care, transitional care, occupational therapy, speech, respiratory and physical therapy), durable equipment and disposable supplies.

8. Documents all activities in the appropriate system(s) on a timely basis.

9. Participates in rounds with the Medical Director.

10. Reviews health plan appeal items for concurrent and retrospective reviews as required and requested.

11. Monitors and facilities appropriate utilization of resources using appropriate clinical criteria.

12. Participates in a multi-disciplinary clinical team to achieve positive member outcomes; Functions as a resource to the clinical team regarding approved criteria, practice guidelines and alternative treatment options.

13. Other duties as requested or assigned.

Qualifications:

EDUCATION AND EXPERIENCE

Education

Required:
- Nursing Diploma.
- Associate’s Degree in related Health/Nursing field.

Preferred:
- Bachelor’s Degree in related Health/Nursing field.

Years and Type of Experience Required:

Required:
- Minimum of two years of utilization management or hospital/acute care experience.

Preferred:
- Minimum of three years experience in health care, case management, discharge planning, utilization management, or behavioral health.
- Experience working on the community level and with community agencies.

Certifications or Licensures

Required:
- RN
- Must possess a valid driver’s license and access to a motor vehicle.

Preferred:
- Certified Professional Healthcare Management

Language Skills

Required:
- English

Preferred:
- Bilingual

Functional Competencies
- Proficient in the use of Microsoft Office tools. Able to use basic office equipment such as telephone, fax machine and copy machine. Use of Internet and working knowledge in a windows environment to include navigation skills using a mouse, keyboard and number pad Ability to review and draft correspondence in email system and word processing systems.
- Experience working with utilization management data systems.

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
]]>Fri, 17 May 2013 00:00:00 GMThttp://www.amerigroup-jobs.com/job/New-York-Utilization-Manager-RN-Inpatient-Job-NY/2604268/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSShttp://www.amerigroup-jobs.com/job/New-York-Utilization-Manager-RN-Inpatient-Job-NY/2604268/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS
Job ID 2013-22485 # Positions 1
Location US-LA-Metairie
Search Category Medical Director
Type Regular Full-Time (30+ hours) Posted Date 4/4/2013
Additional Locations ..

More information about this job:
Summary:

Provides support in overseeing medical care for Amerigroup products and services and works collaboratively with other functions that interface with medical management such as provider relations, member services, benefits and claims management. Collaborates with other business leaders, corporate and health plan medical directors to carry out national medical policies.

Responsibilities:

1. Assists in managing medical costs and assuring appropriate health care delivery for Amerigroup health plans, products and services.

2. Provides guidance, support and leadership for utilization management activities.

3. Supports Medical Director(s) in all aspects of utilization, quality and network management.

4. Provides support to nurses and clinical leaders in pre-authorization, concurrent and retrospective review decisions, case management and disease management decisions.

5. Assists Medical Directors and/or National Medical Directors with medical policy; participates in policy review, reviews trends and makes recommendations; may plan, organize and/or direct medical services programs, consisting of all primary and specialty services for in-patient, out-patient, preventive and wellness programs.

6. Assists in the design and implementation of corrective action plans to address issues and improve plan and network managed care performance.

7. Supports URAC, AHCA and NCQA qualification activities. Prepare for site visits and responds to accrediting and regulatory agency feedback.

8. Participates in risk management, claims adjudication, utilization management, catastrophic case review, education and outreach programs, HEDIS reporting, credentialing, peer to peer review, appeals review, denials, etc.

9. Participates in the development of strategic planning for existing and expanding business. Recommends changes in program content in concurrence with changing markets and technologies.

10. Other duties as assigned or requested

Qualifications:

EDUCATION AND EXPERIENCE

Education

Required:
- MD or DO, with board certification in area of specialty.

Preferred:
- Masters in Public Health, MBA or MA.

Years and Type of Experience Required:

Required:
- Minimum of five years clinical experience with at least two years in medical management/health administration in a managed care environment.

Certifications or Licensures

Required:
- Active license to practice medicine without restriction issued by the State Board of Licensure or the State Board of Osteopathic Examiners. Certified in a recognized medical specialty as recognized by the American Board of Medical Specialists (ABMS).

Preferred:
- Certification by the American Board of Quality Assurance and Utilization Review Physicians or the American Board of Medical Management

Language Skills

Required:
- English

Functional Competencies
- Think creatively, Innovative
- Understanding of financial and business acumen
- Collaborative team player; active listening skills
- Excellent verbal and written communication skills and ability to build and sustain strong working relationships
- Organizational skills and demonstrated ability to multitask and execute
- Strong people leadership and influencing skills
- Strong project management skills; ability to drive programs and lead change
- Knowledge of medical, quality improvement and utilization management practices in a managed care environment
- Knowledge of regulatory and accreditation agencies and requirements
- Ability to use software and hardware of a computer to complete certain moderate to 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. Ability to use of complex applications of software to analyze and solve business problems.
- Ability to read, comprehend and interpret complex information and trends to provide accurate and appropriate information to business partners and/or customers.
- Ability to research information using available resources and determine where gaps in information exist to seek other sources.

SCOPE INFORMATION

# Direct Reports: As assigned

# Indirect Reports: As assigned

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.

CB1

ermEL
]]>Fri, 03 May 2013 03:00:00 GMThttp://www.amerigroup-jobs.com/job/Metairie-Medical-Director-New-Orleans-Job-LA-70001/2530353/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSShttp://www.amerigroup-jobs.com/job/Metairie-Medical-Director-New-Orleans-Job-LA-70001/2530353/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS
Job ID 2013-22705 # Positions 1
Location US-TX-Grand Prairie
Search Category Nursing
Type Regular Full-Time (30+ hours) Posted Date 4/29/2013
Additional Locations ..

More information about this job:
Summary:

Responsible for the coordination of the Medical Director decision process, interfacing with HCMS and/or Quality Management Leadership for appeals. Responsible for reviewing, processing and reporting all Medical Director decision appeals including the assessment of medical records or clinical information and applying approved criteria to ensure appropriate processing and that all regulatory, state, and contractual requirements are met. Assures that the documentation and systems are updated to reflect the medical decisions and will collaborate/assist the Medical Director, Members and Providers.

Responsibilities:

1. Performs on-site and/or telephonic review of acute and sub acute services.

2. Predicts and plans for patient’s needs from pre-admission, through acute and sub acute care and post-discharge, in collaboration with the member.

3. Utilizes pre-approved criteria and guidelines to validate medical necessity of continued stay and appropriateness of treatment and discharge planning.

4. Acts in conjunction with the appropriate manager(s) on a daily basis to assess the inpatient census for appropriate alternative health care service needs.

5. Coordinates with appropriate discharge planning team members, facility utilization management department, physicians and members to coordinate timely discharges.

6. Participates in Quality Improvement Process; tracks and reports trends of inappropriate utilization of resources to the Medical Director; identifies and reports any quality or utilization issues to the Medical Director.

7. Acts in conjunction with the clinical team related to discharge planning (e.g., home care, hospice care, rehabilitation care, special program care, transitional care, occupational therapy, speech, respiratory and physical therapy), durable equipment and disposable supplies.

8. Documents all activities in the appropriate system(s) on a timely basis.

9. Participates in rounds with the Medical Director.

10. Reviews health plan appeal items for concurrent and retrospective reviews as required and requested.

11. Monitors and facilities appropriate utilization of resources using appropriate clinical criteria.

12. Participates in a multi-disciplinary clinical team to achieve positive member outcomes; Functions as a resource to the clinical team regarding approved criteria, practice guidelines and alternative treatment options.

13. Other duties as requested or assigned.

Qualifications:

EDUCATION AND EXPERIENCE

Education

Required:
- Nursing Diploma.
- Associate’s Degree in related Health/Nursing field.

Preferred:
- Bachelor’s Degree in related Health/Nursing field.

Years and Type of Experience Required:

Required:
- Minimum of two years of utilization management or hospital/acute care experience.

Preferred:
- Minimum of three years experience in health care, case management, discharge planning, utilization management, or behavioral health.
- Experience working on the community level and with community agencies.

Certifications or Licensures

Required:
- LPN, LVN or LSW (depending on health plan needs or as mandated by state contract).
- Must possess a valid driver’s license and access to a motor vehicle.
- For Behavioral Health Dept/Specialty Requirements only: LMFT, LPC, LCSW.

Preferred:
- Certified Professional Healthcare Management.

Language Skills

Required:
- English

Preferred:
- Bilingual

Functional Competencies
- Proficient in the use of Microsoft Office tools. Able to use basic office equipment such as telephone, fax machine and copy machine. Use of Internet and working knowledge in a windows environment to include navigation skills using a mouse, keyboard and number pad Ability to review and draft correspondence in email system and word processing systems.
- Experience working with utilization management data systems.

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
]]>Mon, 29 Apr 2013 00:00:00 GMThttp://www.amerigroup-jobs.com/job/Grand-Prairie-Utilization-Manager-Job-TX-75050/2571113/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSShttp://www.amerigroup-jobs.com/job/Grand-Prairie-Utilization-Manager-Job-TX-75050/2571113/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS
Job ID 2013-22785 # Positions 1
Location US-TX-Houston
Search Category Medical Director
Type Regular Full-Time (30+ hours) Posted Date 5/7/2013
Additional Locations ..

More information about this job:
Summary:

AMERIGROUP CORPORATION

MEDICAL DIRECTOR BEHAVORIAL HEALTH Houston

Amerigroup is a Fortune 500 company serving approximately 2 million members in 14 states. Nationwide, we serve one out of every 35 Medicaid recipients and one out of every 25 kids covered by CHIP.

We improve access to quality health care for our members while lowering costs for taxpayers. We coordinate services for individuals in publicly funded health care programs.

Amerigroup accepts all eligible people regardless of age, sex, race or disability.

Our product offerings do not utilize any individual underwriting nor deny coverage due to pre-existing medical conditions. Amerigroup is dedicated to offering real solutions that improve health care access and quality for its members, while proactively working to reduce the overall cost of care to taxpayers.

JOB SUMMARY

Oversees all behavioral health care for AMERIGROUP products and services in Houston. Oversees the health care needs of the membership and serves as the principal behavioral health manager and policy advisor to the company and health plan CEO or COO. Is accountable for and provides professional leadership and direction to the utilization/cost management and clinical quality management functions. Works collaboratively with other plan functions that interface with behavioral health management such as medical management, provider relations, member services, benefits and claims management, etc. Assists in short and long range program planning, total quality management (quality improvement) and external relationships. Works with Corporate Health and Medical Affairs for support, assistance and direction in overall behavioral health management effectiveness. Reports all issues of clinical quality management to the health plan CEO, COO, the Board and the Chief Medical Officer (CMO) of AMERIGROUP Corporation. Collaborates with the CMO, the National Medical Director of Behavioral Health and other health plan medical directors on national medical policies and carries out national medical policies at the health plan in collaboration with the health plan CEO or COO

Responsibilities:

1. Assists in managing medical costs and assuring appropriate health care delivery for Amerigroup health plans, products and services.

2. Provides guidance, support and leadership for utilization management activities.

3. Supports Medical Director(s) in all aspects of utilization, quality and network management.

4. Provides support to nurses and clinical leaders in pre-authorization, concurrent and retrospective review decisions, case management and disease management decisions.

5. Assists Medical Directors and/or National Medical Directors with medical policy; participates in policy review, reviews trends and makes recommendations; may plan, organize and/or direct medical services programs, consisting of all primary and specialty services for in-patient, out-patient, preventive and wellness programs.

6. Assists in the design and implementation of corrective action plans to address issues and improve plan and network managed care performance.

7. Supports URAC, AHCA and NCQA qualification activities. Prepare for site visits and responds to accrediting and regulatory agency feedback.

8. Participates in risk management, claims adjudication, utilization management, catastrophic case review, education and outreach programs, HEDIS reporting, credentialing, peer to peer review, appeals review, denials, etc.

9. Participates in the development of strategic planning for existing and expanding business. Recommends changes in program content in concurrence with changing markets and technologies.

10. Other duties as assigned or requested.

Qualifications:

EDUCATION AND EXPERIENCE

Education

Required:

Medical Doctor with specialization and board certification in Psychiatry. - Continuing education to remain current in behavioral health and management areas. - Any equivalent combination of education and experience. Years and Type of Experience Required: Required: - Five years of clinical experience in the practice of medicine, two of which have been in medical and/or health administration. - Three to five years of management and /or clinical experience in a managed care environment. Certifications or Licensure Required: •Board Certified in Psychiatry. - Must be licensed in the state of Texas as a Doctor of Medicine or be able to achieve such licensure upon hire- Active license to practice medicine without restriction issued by the State Board of Licensure or the State Board of Examiners. Preferred: - Certification by the American Board of Quality Assurance and Utilization Review Physicians or the American Board of Medical Management desired but not required. Other Required: - Management skills to meet the organizational goals. - Must possess excellent communications skills to interface with providers, staff, and management. - Knowledge of behavioral health, quality improvement and UM practices in a managed care environment. - Knowledge of regulatory and accreditation agencies and requirements. - Able to manage multiple priorities and deadlines in an expedient and decisive manner. - Able to manage difficult peer situations arising from medical care review. - Appreciation of cultural diversity and sensitivity towards target population. PHYSICAL REQUIREMENTS: - Must be able to operate a computer. - Must be able to operate a telephone. - Must be able to travel on common carriers and to adhere to AMERIGROUP’s travel policies. - Must be able to operate a motor vehicle. - Must be able to conduct and participate in meetings

Preferred:
- Board Certification in Addictionology or substantial clinical experience in substance use disorders OR Child Psychiarty
- Masters in Public Health, MBA or MA.
- Certification by the American Board of Quality Assurance and Utilization Review Physicians or the American Board of Medical Management

Language Skills

Required:
- English

Functional Competencies
- Think creatively, Innovative
- Understanding of financial and business acumen
- Collaborative team player; active listening skills
- Excellent verbal and written communication skills and ability to build and sustain strong working relationships
- Organizational skills and demonstrated ability to multitask and execute
- Strong people leadership and influencing skills
- Strong project management skills; ability to drive programs and lead change
- Knowledge of medical, quality improvement and utilization management practices in a managed care environment
- Knowledge of regulatory and accreditation agencies and requirements
- Ability to use software and hardware of a computer to complete certain moderate to 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. Ability to use of complex applications of software to analyze and solve business problems.
- Ability to read, comprehend and interpret complex information and trends to provide accurate and appropriate information to business partners and/or customers.
- Ability to research information using available resources and determine where gaps in information exist to seek other sources.

SCOPE INFORMATION

# Direct Reports: As assigned

# Indirect Reports: As assigned

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

CB1

ermEL
]]>Tue, 07 May 2013 00:00:00 GMThttp://www.amerigroup-jobs.com/job/Houston-Medical-Director-Behavorial-Health-Job-TX-77001/2585343/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSShttp://www.amerigroup-jobs.com/job/Houston-Medical-Director-Behavorial-Health-Job-TX-77001/2585343/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS
Job ID 2012-20924 # Positions 1
Location US-KS-Overland Park
Search Category Medical Director
Type Regular Part-Time (20-29 hours) Posted Date 10/12/2012
Additional Locations ..

More information about this job:
Summary:

Amerigroup is a Fortune 500 company serving approximately 2 million members in 14 states. Nationwide, we serve one out of every 35 Medicaid recipients and one out of every 25 kids covered by CHIP.

We improve access to quality health care for our members while lowering costs for taxpayers. We coordinate services for individuals in publicly funded health care programs.

Amerigroup accepts all eligible people regardless of age, sex, race or disability.

Our product offerings do not utilize any individual underwriting nor deny coverage due to pre-existing medical conditions. Amerigroup is dedicated to offering real solutions that improve health care access and quality for its members, while proactively working to reduce the overall cost of care to taxpayers.

Responsibilities:

Provides support and leadership around behavioral health care for AMERIGROUP products and services in Kansas.. Provides professional leadership and direction to the utilization/cost management and clinical quality management functions. Works collaboratively with other plan functions that interface with behavioral health management such as medical management, provider relations, member services, benefits and claims management, etc. Assists in short and long range program planning, total quality management (quality improvement) and external relationships. Works with Corporate Health and Medical Affairs for support, assistance and direction in overall behavioral health management effectiveness.. Collaborates with the CMO, the National Medical Director of Behavioral Health and other health plan medical directors on national medical policies and carries out national medical policies at the health plan in collaboration with the health plan CEO or COO.

Qualifications:

EDUCATION AND EXPERIENCE

Education

Required:
- MD or DO, with board certification in area of specialty.

Preferred:
- Masters in Public Health, MBA or MA.

Years and Type of Experience Required:

Required:
- Minimum of five years clinical experience with at least two years in medical management/health administration in a managed care environment.

Certifications or Licensures

Required:
- Active license to practice medicine without restriction issued by the State Board of Licensure or the State Board of Osteopathic Examiners. Certified in a recognized medical specialty as recognized by the American Board of Medical Specialists (ABMS).

Preferred:
- Certification by the American Board of Quality Assurance and Utilization Review Physicians or the American Board of Medical Management

Language Skills

Required:
- English

Functional Competencies
- Think creatively, Innovative
- Understanding of financial and business acumen
- Collaborative team player; active listening skills
- Excellent verbal and written communication skills and ability to build and sustain strong working relationships
- Organizational skills and demonstrated ability to multitask and execute
- Strong people leadership and influencing skills
- Strong project management skills; ability to drive programs and lead change
- Knowledge of medical, quality improvement and utilization management practices in a managed care environment
- Knowledge of regulatory and accreditation agencies and requirements
- Ability to use software and hardware of a computer to complete certain moderate to 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. Ability to use of complex applications of software to analyze and solve business problems.
- Ability to read, comprehend and interpret complex information and trends to provide accurate and appropriate information to business partners and/or customers.
- Ability to research information using available resources and determine where gaps in information exist to seek other sources.

SCOPE INFORMATION

# Direct Reports: As assigned

# Indirect Reports: As assigned

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.

HEC:DW

ermEL
]]>Sun, 28 Apr 2013 03:00:00 GMThttp://www.amerigroup-jobs.com/job/Overland-Park-Medical-Director-Behavorial-Health-Part-Time-Job-KS-66062/2211141/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSShttp://www.amerigroup-jobs.com/job/Overland-Park-Medical-Director-Behavorial-Health-Part-Time-Job-KS-66062/2211141/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS
Job ID 2012-20398 # Positions 1
Location US-TX-Grand Prairie
Search Category Medical Director
Type Regular Full-Time (30+ hours) Posted Date 9/11/2012
Additional Locations ..

More information about this job:
Summary:

Responsible and accountable for assuring appropriate health care delivery for Amerigroup health plans, products and services. Leads, develops, directs and implements clinical and non-clinical activities that impact health care quality, cost and outcomes. Interprets existing medical policies and participates in the development and execution of new policies based on changes in the healthcare or medical arena Supports medical management and other health plan staff in timely and consistent responses to members and providers.

Responsibilities:

1. Designs and implements corporate and/or health plan medical policies, goals and objectives, reviews trends and makes recommendations; plans, organizes and directs medical services programs, consisting of all primary and specialty services for in-patient, out-patient, preventive and wellness programs.

2. Assists with the development of budgets, staffing plans and medical loss ratio projections, assuring the adequate allocation of resources to the medical management functions.

3. Provides professional leadership and direction to the functions within Medical Management, to include Utilization and Case Management, Cost Management and Clinical Quality Management.

4. Drives provider collaboration initiatives and performance monitoring; designs and implements corrective action plans to address issues and improve plan and network managed care performance.

5. Collaborates with provider and government/external relations to improve brand reputation and credibility with constituents.

6. Participates in the retrospective review and analysis of health plan performance from analyzing trends and summary data of paid claims, encounters, authorization logs, complaint and grievance logs and other sources.

7. Supports URAC, AHCA and NCQA qualification activities. Prepares for site visits and responds to accrediting and regulatory agency feedback.

8. Participates in risk management, claims adjudication, utilization management, catastrophic case review, education and outreach programs, HEDIS reporting, credentialing, peer to peer review, appeals review, denials, etc.

9. Participates in the development of strategic planning for existing and expanding business. Recommends changes in program content in concurrence with changing markets and technologies.

10. Monitors member and provider satisfaction survey results and implements changes as needed to increase satisfaction and assure that satisfactory relationships are maintained between network and plan participants.

11. Assists with the contracting process for providers, hospitals, ancillary providers and emergency and other supports services and evaluates the medical aspects of provider contracts.

12. Other duties as assigned or requested

Qualifications:

EDUCATION AND EXPERIENCE

Education

Required:
- MD or DO, with board certification in area of specialty

Preferred:
- Masters in Public Health, MBA or MA Years and Type of Experience Required: Required:
- Minimum of ten years clinical experience with at least three years in medical management/health administration in a managed care environment.
- Minimum of 7 years of leadership/management experience.
- Extensive managed care or Medicare knowledge

Certifications or Licensures

Required:
- Active license to practice medicine without restriction issued by the State Board of Licensure or the State Board of Osteopathic Examiners. Certified in a recognized medical specialty as recognized by the American Board of Medical Specialists (ABMS).

Preferred:
- Certification by the American Board of Quality Assurance and Utilization Review Physicians or the American Board of Medical Management

Language Skills

Required:
- English

Functional Competencies
- Think creatively, Innovative
- Understanding of financial and business acumen
- Collaborative team player; active listening skills
- Excellent verbal and written communication skills and ability to build and sustain strong working relationships
- Organizational skills and demonstrated ability to multitask and execute
- Strong people leadership and influencing skills
- Strong project management skills; ability to drive programs and lead change
- Knowledge of medical, quality improvement and utilization management practices in a managed care environment
- Knowledge of regulatory and accreditation agencies and requirements
- Ability to use software and hardware of a computer to complete certain moderate to 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. Ability to use of complex applications of software to analyze and solve business problems.
- Ability to read, comprehend and interpret complex information and trends to provide accurate and appropriate information to business partners and/or customers.
- Ability to research information using available resources and determine where gaps in information exist to seek other sources.

SCOPE INFORMATION

# Direct Reports: 0-5

# Indirect Reports: 0-75

Budgetary $ Responsibility: Varies

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.

HEC:DW

ermEL
]]>Tue, 30 Apr 2013 03:00:00 GMThttp://www.amerigroup-jobs.com/job/Houston-Sr-Medical-Dir-Job-TX-77001/2144639/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSShttp://www.amerigroup-jobs.com/job/Houston-Sr-Medical-Dir-Job-TX-77001/2144639/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS
Job ID 2013-22730 # Positions 1
Location US-TX-Grand Prairie
Search Category Medical Director
Type Regular Full-Time (30+ hours) Posted Date 5/2/2013
Additional Locations ..

More information about this job:
Summary:

Responsible and accountable for assuring appropriate health care delivery for Amerigroup health plans, products and services. Leads, develops, directs and implements clinical and non-clinical activities that impact health care quality, cost and outcomes. Interprets existing medical policies and participates in the development and execution of new policies based on changes in the healthcare or medical arena Supports medical management and other health plan staff in timely and consistent responses to members and providers.

Responsibilities:

1. Designs and implements corporate and/or health plan medical policies, goals and objectives, reviews trends and makes recommendations; plans, organizes and directs medical services programs, consisting of all primary and specialty services for in-patient, out-patient, preventive and wellness programs.

2. Assists with the development of budgets, staffing plans and medical loss ratio projections, assuring the adequate allocation of resources to the medical management functions.

3. Provides professional leadership and direction to the functions within Medical Management, to include Utilization and Case Management, Cost Management and Clinical Quality Management.

4. Drives provider collaboration initiatives and performance monitoring; designs and implements corrective action plans to address issues and improve plan and network managed care performance.

5. Collaborates with provider and government/external relations to improve brand reputation and credibility with constituents.

6. Participates in the retrospective review and analysis of health plan performance from analyzing trends and summary data of paid claims, encounters, authorization logs, complaint and grievance logs and other sources.

7. Supports URAC, AHCA and NCQA qualification activities. Prepares for site visits and responds to accrediting and regulatory agency feedback.

8. Participates in risk management, claims adjudication, utilization management, catastrophic case review, education and outreach programs, HEDIS reporting, credentialing, peer to peer review, appeals review, denials, etc.

9. Participates in the development of strategic planning for existing and expanding business. Recommends changes in program content in concurrence with changing markets and technologies.

10. Monitors member and provider satisfaction survey results and implements changes as needed to increase satisfaction and assure that satisfactory relationships are maintained between network and plan participants.

11. Assists with the contracting process for providers, hospitals, ancillary providers and emergency and other supports services and evaluates the medical aspects of provider contracts.

12. Other duties as assigned or requested

Qualifications:

EDUCATION AND EXPERIENCE

Education

Required:
- MD or DO, with board certification in area of specialty

Preferred:
- Masters in Public Health, MBA or MA Years and Type of Experience Required: Required:
- Minimum of ten years clinical experience with at least three years in medical management/health administration in a managed care environment.
- Minimum of 7 years of leadership/management experience.
- Extensive managed care or Medicare knowledge

Certifications or Licensures

Required:
- Active license to practice medicine without restriction issued by the State Board of Licensure or the State Board of Osteopathic Examiners. Certified in a recognized medical specialty as recognized by the American Board of Medical Specialists (ABMS).

Preferred:
- Certification by the American Board of Quality Assurance and Utilization Review Physicians or the American Board of Medical Management

Language Skills

Required:
- English

Functional Competencies
- Think creatively, Innovative
- Understanding of financial and business acumen
- Collaborative team player; active listening skills
- Excellent verbal and written communication skills and ability to build and sustain strong working relationships
- Organizational skills and demonstrated ability to multitask and execute
- Strong people leadership and influencing skills
- Strong project management skills; ability to drive programs and lead change
- Knowledge of medical, quality improvement and utilization management practices in a managed care environment
- Knowledge of regulatory and accreditation agencies and requirements
- Ability to use software and hardware of a computer to complete certain moderate to 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. Ability to use of complex applications of software to analyze and solve business problems.
- Ability to read, comprehend and interpret complex information and trends to provide accurate and appropriate information to business partners and/or customers.
- Ability to research information using available resources and determine where gaps in information exist to seek other sources.

SCOPE INFORMATION

# Direct Reports: 0-5

# Indirect Reports: 0-75

Budgetary $ Responsibility: Varies

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.

CB1

ermEL
]]>Thu, 02 May 2013 00:00:00 GMThttp://www.amerigroup-jobs.com/job/Grand-Prairie-Sr-Medical-Dir-DFW-TEXAS-Job-TX-75050/2578754/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSShttp://www.amerigroup-jobs.com/job/Grand-Prairie-Sr-Medical-Dir-DFW-TEXAS-Job-TX-75050/2578754/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS
Job ID 2013-22140 # Positions 1
Location US-VA-Norfolk
Search Category Health Care Operations
Type Regular Full-Time (30+ hours) Posted Date 2/28/2013
Additional Locations ..

More information about this job:
Summary:

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

Responsibilities:

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

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

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

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

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

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

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

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

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

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

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

13. Performs other duties as assigned or requested.

Qualifications:

EDUCATION REQUIREMENTS

Education

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

Years and Type of Experience Required:

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

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

Certifications or Licensures

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

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

Language Skills

Required:
- English

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

PHYSICAL REQUIREMENTS

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

ermHO
]]>Sat, 27 Apr 2013 03:00:00 GMThttp://www.amerigroup-jobs.com/job/Norfolk-Clinical-Auditor-Reimbursement-Job-VA-23501/2455579/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSShttp://www.amerigroup-jobs.com/job/Norfolk-Clinical-Auditor-Reimbursement-Job-VA-23501/2455579/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS
Job ID 2013-22613 # Positions 1
Location US-VA-Chesapeake
Search Category Information Technology
Type Regular Full-Time (30+ hours) Posted Date 4/17/2013
Additional Locations ..

More information about this job:
Summary:

In accordance with the Project Management Body of Knowledge (PMBOK) and PMI standards, in conjunction with the VP Project Manager, Functional Area Manager or Company Executive, responsible for the coordinated leadership of multiple related projects, and ongoing operations, which are directed toward a common organizational objective. Directs high-priority projects, requiring considerable resources and high levels of functional integration. Responsible for all aspects of the program over the entire life cycle (initiate, plan, execute, control, close). Directs Project Managers for the execution of their project and its impact on the program to monitor cost, schedule, and technical performance of component projects and operations, while working to ensure the ultimate success of the program. Responsible for assembling program/project team, assigning individual responsibilities, identifying appropriate resources needed, and developing schedule to ensure timely completion of project. Responsible for determining the sharing of resources among their constituent projects to the overall benefit of the program. Takes projects from original concept through final implementation. Interfaces with all areas affected by the project including end users, distributors, and vendors.

Responsibilities:

1. Manage and monitor overall performance of direct reports to include Project Manager, Project coordinators, and other functional specialists.

2. Manage program change in accordance with the change management plan to control scope, quality, schedule, cost, and contracts.

3. Address program issues by identifying and selecting a course of action by taking into account the program constraints and objectives in order to enable continued program progress.

4. Motivate the team using appropriate tools and techniques in order to increase commitment to the program objectives.

5. Execute program plans (quality, risk, communication, staffing, etc.) by using the tools identified in the planning phase and by auditing the results of their use in order to align the program outcomes with stakeholder expectations and standards.

6. Develop a high-level milestone plan using goals and objectives of the program, applicable historical information, and other available resources in order to align program with expectations of sponsors and stakeholders.

7. Establish alliances with other departments and organizations by recognizing dependencies in order to assess potential partnership and commitment to the program.

8. Capture program status and data by ensuring the population of the program management information system in order to maintain accurate and current program information for the use of stakeholders.

9. Obtain senior management approval for the program by presenting the program charter with its high-level costs and benefits for the organization in order to receive authorization to proceed to the next phases.

10. Manage changes to the program scope, program schedule, and program costs using appropriate verification techniques in order to keep the program plan accurate, updated, reflective of authorized program changes as defined in the change management plan, and facilitate customer acceptance.

11. Ensure a common understanding by setting expectations in accordance with the Program Plan, in order to align the stakeholders and team members.

12. Record detailed customer requirements, constraints, and assumptions with stakeholders in order to establish the program deliverables, using requirement-gathering techniques (e.g., planning sessions, brainstorming, focus groups) and the program charter.

13. Measure program performance using appropriate tools and techniques in order to monitor the progress of the program, identify and quantify any variances, perform any required corrective actions, and communicate to all stakeholders.

14. Document high-level risks, assumptions, and constraints using historical data and expert judgment in order to understand program limitations.

15. Improve team performance by building team cohesiveness, leading, mentoring, training, and motivating in order to facilitate cooperation, ensure program efficiency, and boost morale.

Qualifications:

EDUCATION AND EXPERIENCE

Education

Required:
- Bachelors Degree or equivalent.

Preferred:
- Masters Degree

Years and Type of Experience Required:

Required:
- 7 - 10 years Program/Project Management.
- 3 years leadership/management experience.

Preferred:
- Health care insurance industry experience.
- Business analysis and process improvement experience.
- MS Project, Outlook, PowerPoint and Visio experience.
- Survey tools experience, e.g. Survey Monkey.

Certifications or Licensures

Required:
- PMI PMP (Project Management Professional) or ability to obtain within first six – 12 months depending upon department requirements.

Preferred:
- PMI PMP (Program Management Professional).
- IIBA CCBA (Certification of Competency in Business Analysis) or Six Sigma Black Belt.

Language Skills

Required:
- English

Technical Competencies

Project Management - Expert
- Ability to coordinate and lead multiple related large, complex projects in accordance with Project Management Body of Knowledge (PMBOK) and Project Management Institute (PMI) standards. Solid understanding of process improvement and project management including tools and techniques, critical path method, program evaluation and review technique, resource balancing and cost estimating. Ability to clarify and interpret the relationships between a system and its component parts.

Industry Knowledge & Familiarity - Advanced
- Deep understanding of the healthcare industry and government insurance programs, e.g. Medicare, Medicaid, CHIP and LTC.

Computer Skills and Office Equipment - Advanced
- Ability to use software and hardware of a computer to complete certain moderately-complex to complex tasks. Able to use basic office equipment such as telephone, fax machine and copy machine. Working knowledge in a windows environment to include navigation skills using a mouse, keyboard and 10 key. Use of internet, familiarity with SharePoint sites. Ability to review and draft correspondence in email system and word processing systems.
- Ability to use project management and related software, e.g. MS Project, VISIO, SharePoint. 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).

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: 2 - 10

Project Budget Range: $500,000 to $20 Million Project

Team Size: 10 - 50

Project Duration: 18 – 24 months Project Timeline: Aggressive to Very Aggressive Timeline

Project Risk: High # of System Interfaces: Multiple

#of Geographical Regions: 2 Plus

# of Functional Disciplines/Stakeholders: Multiple

# of Sub-Projects: Multiple

Level of Innovation / Means to Achieve Goals: Primarily Existing / Minor Modifications

Project Scope Definition: Moderately Defined to Innovative

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
]]>Thu, 16 May 2013 02:59:00 GMThttp://www.amerigroup-jobs.com/job/Chesapeake-Director-Project-Management-Job-VA-23320/2551830/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSShttp://www.amerigroup-jobs.com/job/Chesapeake-Director-Project-Management-Job-VA-23320/2551830/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS
Job ID 2013-22717 # Positions 1
Location US-NY-New York
Search Category Health Care Operations
Type Regular Full-Time (30+ hours) Posted Date 5/3/2013
Additional Locations ..

More information about this job:
Summary:

Responsible for supporting the development, implementation and coordination of a comprehensive health care program in which members’ needs are identified, including physical health, behavioral health, social services and long term service and supports (LTSS).

Responsible for overseeing the referral and enrollment functions of the Managed Long Term Care plan. This would include oversight of a dedicated call center staff as well as the electronic enrollment and disenrollment functions of the plan. Ensure that prospective enrollees are appropriately screened within mandated timeframes. Communicates status updates with applicants and referral sources throughout the enrollment process.

Is responsible for regulatory reporting as required by MLTC contract. Will frequently communicate information and statistics internally as well as to SDOH and external entities/partners. Will act as primary liaison to community agencies and referrals partners to support program growth. Manage a staff of community enrollment representatives who conduct outreach activities to applicants, caregivers and referral partners. Responsible for regulatory reporting as required by MLTC contract.

Weekend or after hour availability may occasionally occur to support outreach activities or community events.

Responsibilities:

1. Directs and oversees program operations in a market in support of corporate and health plan management.

2. Directs other health plan functional managers in the organization to develop and implement the action steps necessary to successfully and within budget manage program operations.

3. Collaborates with other functional leaders within AGP health plans that have or will be deploying aspects of the program within established timeframes and planning milestones. Contributes to knowledge sharing environment by creating program documents, giving presentations, teaching and mentoring health plan associates.

4. Participates in various cross-functional workgroups created to maintain / develop program, including developing agenda items, conducting meetings, and publishing accurate minutes to record workgroup activities / decisions.

5. Continually evaluates program operations to improve efficiency of operations, financial return, customer service, and provider engagement.

6. Develops, communicates, and monitors program schedule, budget, and resources plan.

7. Coordinates program deliverables, and drives to resolution any issues that may hinder program success.

8. Provides departments with updates, training and feedback as needed to ensure continued compliance with specific medical management standards, contract regulations, and compliance standards.

9. Manages resource utilization to ensure appropriate delivery of care to members and adequate coverage for all departmental tasks and job responsibilities; while incorporating QA measures and providing appropriate feedback and counseling.

10. Perform other duties as assigned.

Qualifications:

EDUCATION AND EXPERIENCE

Education

Required:
- Bachelor’s degree in related discipline

Preferred:
- Masters degree

Years and Type of Experience Required:

Required:
- Minimum of 7+ years’ relevant work experience and at least 3 years of leadership/management experience within a medium to large sized public sector health care organization preferably managed care organizations.

Preferred:
- Experience in a managed care setting with direct experience in service delivery coordination, discharge planning, or behavioral health.
- Experience working in the community with community agencies.

Certifications or Licensures

Preferred:
- RN, MSW

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.
- Conveys a thorough understanding of own area's strengths, weaknesses, opportunities, and threats.
- Brings to bear the appropriate knowledge, information, and expertise in making decisions.

SCOPE INFORMATION

# Direct Reports: 4-15

# Indirect Reports: 75+

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.

ermHO
]]>Sat, 04 May 2013 00:00:00 GMThttp://www.amerigroup-jobs.com/job/New-York-Director-LTSS-MLTC-NY-Job-NY/2581109/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSShttp://www.amerigroup-jobs.com/job/New-York-Director-LTSS-MLTC-NY-Job-NY/2581109/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS