http://www.amerigroup-jobs.com/go/Atlanta-Managed-Care-Jobs/169075/ View Atlanta Managed Care Jobs at Amerigroup Wed, 08 Sep 2010 02:09:51 GMT en-us /sites/amerigroup/images/banner.gif http://www.amerigroup-jobs.com/go/Atlanta-Managed-Care-Jobs/169075/ 720
Job ID: 2010-11325
# Positions: 1
Location: US-GA-Atlanta
Search Category: Nursing
Type: Regular Full-Time (30+ hours)
Posted Date: 7/23/2010

More information about this job:

Overview:

The Manager of Quality Management is responsible in conjunction with the plan QM leader, the Plan Medical Director and CEO for developing, coordinating, and implementing quality initiatives within the health plan. Provides clinical and technical supervision to a team responsible for monitoring and evaluation the quality of care/service, appropriateness, continuous improvement, member satisfaction, and results of actions across the continuum of care to members. Assist in coordinating the quality management program activities throughout the functional areas of the health plan.

Responsibilities:

1. Assists in establishing objectives and annual goals in conjunction with the plan QM leader, the Plan Medical Director and CEO.

2. In conjunction with the plan QM leader, implements the comprehensive Quality Management Program to meet the demographic and epidemiological needs of the population served.

3. Promotes plan-wide understanding, communication, and coordination of the quality management program.

4. Manages and evaluates teams performance and ensure adherence to departments standards.

5. Trends quality data and develops aggregate and individual plan reports as indicated. Analyzes validity of data/reports.

6. Coordinates on a quarterly basis reporting of all quality/risk initiatives to all appropriate committees.

7. Develops, designs, implements and evaluates activities including coordination of focus studies and other indicators of quality of care/service.

8. Coordinates development, implementation, and evaluation of continuous quality improvement action plans for the improvement activities.

9. Participates in the reporting of the Health Employer Data Information Sets (HEDIS) data and coordinates the improvement action plans.

10. Coordinates the state regulatory quality reporting for the health plan.

11. Provides support for provider recredentialing in the areas of medical record reviews, quality indicators and trended data.

12. Assures compliance with State and Federal quality improvement requirements. Prepares plan staff for successful State and internal audits.

13. Maintains liaison for quality initiatives with State and Federal regulatory agencies as needed.

14. Evaluates and makes recommendations for oversight of delegated services.

15. Assists in developing the annual operating and capital budgets to sufficiently meet departmental needs and ensures that department stays within budget and accounts for variances.

16. Interviews, manages, evaluates, and develops new and existing departmental staff.

17. Recognizes and utilizes appropriate channels for communication and encourages two-way communication and encourages staff to participate in creative program development.

18. Work collaboratively with key health care professionals toward identification of opportunities for improvement, trend analysis, education and development of appropriate action plans for problem resolution.

19. Effectively communicates information to superiors, team members, and other appropriate staff in a timely, accurate, and courteous manner.

20. Actively participates in meetings and helps maintain an effective work group.

21. Develops presentations on activities for a variety of audiences as needed.

22. Other duties as requested or assigned.

Qualifications:

EDUCATION AND EXPERIENCE:

Education

Required:

- Associates Degree

Preferred:

- Bachelors Degree, or MSN, MPH, MPA

Years and Type of Experience Required:

Required:

- Minimum of 5 years of current experience in quality improvement, and/or utilization review in HMO setting with at least 1 year management/leadership experience.

Preferred:

- Previous NCQA accreditation and HEDIS reporting experience preferred
- Experience with the urban Medicaid population preferred

Certifications or Licensure

Required:

- Current state RN license Preferred: Risk Management License preferred; CPHQ preferred.

Other

Required:

- Strong knowledge base in areas of quality improvement.
- Excellent written and verbal communication skills.
- Ability to work effectively with physicians and other health care providers as well as with multi-disciplinary teams across department lines.
- Excellent problem solving skills
- Demonstrates strong organizational skills.
- Knowledge of basic computers including word processing and spreadsheets.
- Ability to work in a team environment.
- Ability to develop and give presentations.
- Ability to handle multiple tasks.
- Appreciation of cultural diversity and sensitivity towards target population S

COPE INFORMATION

- # Direct Reports- 6
- # Indirect Reports-0
- Budgetary $ Responsibility

PHYSICAL REQUIREMENTS

- Must be able to operate a computer.
- Must be able to operate a telephone]]> http://www.amerigroup-jobs.com/job/Virginia-Beach-Management-Analyst-Claims-Job-VA-23450/827287/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS http://www.amerigroup-jobs.com/job/Virginia-Beach-Management-Analyst-Claims-Job-VA-23450/827287/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS
Job ID: 2010-12290
# Positions: 1
Location: US-GA-Atlanta
Search Category: Health Care Operations
Type: Regular Full-Time (30+ hours)
Posted Date: 9/1/2010

More information about this job:

Overview:

The Account Executive (AE) is responsible for Provider Quality Incentive Program initiatives. Account Executive communicates, analyzes and formulates agreement with Claims, Clinical Informatics, Compliance, Finance, Health Plan Healthcare Management Services and Provider Relations, Medical Economics, and Quality Management to reward our large-panel primary care providers and groups who meet quality benchmarks and improvement targets, as well as medical cost management targets. Program quality indicators have been selected based on an analysis of the greatest quality improvement opportunities for our members, and will be measured in a HEDIS-like fashion.

Responsibilities:

1. Conducts market analysis to define large-panel primary care providers and groups who meet quality benchmarks and improvement targets, as well as meets criteria for medical cost management.

2. Assesses and analyzes quality and medical cost data results and manages the Provider Quality Incentive Program (PQIP) on behalf of local health plan. Stays abreast of program development and provides an ongoing objective evaluation of important aspects of data findings to report potential issues or concerns to upper management.

3. Works collaboratively with appropriate staff at various stages in the process. Functional areas are: Claims, Clinical Informatics, Compliance, Finance, Health Plan Healthcare Management Services and Provider Relations, Medical Economics, and Quality Management to analyze data. Make determination for next steps.

4. Educates and trains AGP staff, participating provider & staff, and associated AMERIGROUP leadership on their responsibilities in carrying out the quality improvement program. Chair functional area meetings to review analysis while maintaining Program integrity and in preparation for presentations to Committee.

5. Collects, analyzes and summarizes performance data, identifying opportunities for improvement and present finding to QPIP Committee.

6. Conducts meeting(s) with large-panel primary care providers and groups before and after they enter the QPIP Program. Monitor quality data and improvement targets as well as medical cost management targets. Review detailed analysis with provider to promote improvement in quality and management of service delivery.

7. Reviews new or modified program enhancements to determine if proposed processes are and/or will continue performing according to program specifications; if results potential yield a negative impact, conform by changing aspects where necessary. Recommends program improvements or corrections QPIP Committee.

8. Works with Providers to understand issues/concerns. Identifies root cause of problems and trends and participates in developing solutions. Works with Provider's staff and AMERIGROUP staff (local and/or corporate) to resolve the issue and monitor recurrence.

9. Assist with training and mentoring of the Provider Relations Representatives as needed to ensure departmental success and effective team work. In the absence of management, acts as the lead or senior associate in the department or for the assigned team.

10. Track and respond to in-person, telephonic, and written inquiries from providers and document all contacts in appropriate system per Plan (i.e. Sales force).

11. Performs other duties and special projects as assigned.

Qualifications:

Education Required:

Bachelor's degree in Business Administration & Management, Healthcare Administration and Management, or Nursing Preferred: Certified Medical Office Manager (CMOM), Quality Improvement Analyst/Mgr.

Years and Type of Experience Required: Required:

Minimum 5 years experience of practice manager, business analyst, claims manager, healthcare business office manager or outpatient clinic administrator Preferred: 3 years as a member of Practice Management Institute Specific Technical Skills Required: ' Ability to cultivate and maintain positive internal and external relationships ' Ability to work independently ' Ability to analyze and interpret statistical data ' Ability to effectively communicate statistical and qualitative interpretations in a non-offensive manner to medical professionals and staff ' Ability to guide the provider to better performance ' Experienced in CPT and ICD-9 Coding ' Experienced in running reports and developing presentations ' Excellent verbal and written communications skills ' Effective management skills ' organization, planning, setting goals and objectives, time management ' Effective leadership skills ' Excellent interpersonal skills ' Excellent social skills ' Thorough appreciation of cultural diversity and sensitivity toward target populations Certifications or Licensure Required: Preferred: CMOM, Certified Medical Coder (CMC), Registered Nurse or Licensed Practical Nurse

PHYSICAL REQUIREMENTS

' Must be able to operate a computer ' Must be able to operate a telephone ' Must be able to conduct and participate in meetings ' Must be able to travel on common carriers and adhere to AMERIGROUP's travel policies]]> http://www.amerigroup-jobs.com/job/Atlanta-Provider-Accnt-Executive-Plan-GA-30301/924297/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS http://www.amerigroup-jobs.com/job/Atlanta-Provider-Accnt-Executive-Plan-GA-30301/924297/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS
Job ID: 2010-12022
# Positions: 1
Location: US-GA-Atlanta
Search Category: Nursing
Type: Regular Full-Time (30+ hours)
Posted Date: 7/27/2010

More information about this job:

Overview:

JOB SUMMARY: The HCMS manager is responsible for providing clinical supervision to a team responsible for coordinating member service, utilization, access, and concurrent review to ensure cost effective utilization of health, mental health, and substance abuse services.

Responsibilities:

PRIMARY RESPONSIBILITIES:

1. Manages and oversees team responsible in case finding and coordinating those cases that involve comorbid conditions and need to be part of the case management/disease management track.

2. Manages and evaluates team's performance and ensure adherence to department's standards

3. Responsible for coordination and service delivery to include member assessment of physical and psychological factors.

4. Works with providers to establish short and long term goals that meet the member's need, functional abilities and referral sources requirements.

5. Communicates care plan objectives utilizing community resources to individuals, departments, and providers identified as having a role in the care of members.

6. Coordinates the identifications of members with potential for high risk complications.

7. Assesses members' present level of physical/mental impairment utilizing defined criteria and methodology.

8. Demonstrates understanding of the physical and psychological characteristics of illness, disabilities and wellness and makes referrals when appropriate.

9. Review benefit systems and cost benefit analysis.

10. Evaluates the member against level of care criteria.

11. Demonstrates knowledge of utilization management targets.

12. Acquires data and evaluates necessary medical, mental health and substance abuse service for cost containment.

13. Requests direction from Medical Director on complex healthcare issues.

14. Maintains member confidentiality and respect of the patient bill of rights.

15. Other duties as assigned.

Qualifications:

EDUCATION AND EXPERIENCE:

Education Required:

Bachelors Degree, or equivalent work experience Preferred: MSN, MPH, MPA, or MSW or related or MBA with Health Care Concentration

Years and Type of Experience Required: Required:

Five years experience in health Care Management and at least one year of leadership/management experience.

Knowledge and Technical Skills Required:

Knowledge of community resources

Basic Computer skills to include Microsoft Word and Excel

Ability to provide supervision to multidisciplinary team

Strong decision making skills

Ability to provide services in an environment that involves multiple health, mental health and substance abuse care systems.

Ability to interact with all relevant components of the health and behavioral health care systems

Self starter with the ability to handle multiple projects at one time.

Certifications or Licensure Required: RN, or PA, or LSW, or LPC, or LMHC Preferred: Certified Case Manager

SCOPE INFORMATION

Item Measure ' # Direct Reports 2-10 (or individual contributor in a coaching/training capacity within the department)

Budgetary $ Responsibility none

PHYSICAL REQUIREMENTS

Able to operate a computer

Able to operate a telephone

Required License: LSW, LPC, LMHC or LMSP with Master's Level preparation

Must have valid driver's license

Ability to travel on commercial airliner when needed]]> http://www.amerigroup-jobs.com/job/Atlanta-Manager,-Health-Care-Mgmnt-Services-Job-GA-30301/888663/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS http://www.amerigroup-jobs.com/job/Atlanta-Manager,-Health-Care-Mgmnt-Services-Job-GA-30301/888663/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS
Job ID: 2010-12245
# Positions: 1
Location: US-GA-Atlanta
Search Category: Sales & Marketing
Type: Regular Full-Time (30+ hours)
Posted Date: 8/27/2010

More information about this job:

Overview:

JOB SUMMARY: Responsible for establishing/maintaining/monitoring activities that will with regulators and elected officials that will impact Amerigroup's business while maintaining an understanding of Amerigroup's mission and values. Will work closely with the VP, Government Relations to formulate and execute regulatory and legislative strategy.

Responsibilities:

PRIMARY RESPONSIBILITIES: 1. Monitor and coordinate responses to state or Federal legislation or anticipated legislative initiatives and regulatory changes. 2. Work with Operations, Business Development, and Government Relations to establish and implement strategies to bring new products or expansions of current products to market areas 3. Work with regulators on reporting and other regulatory matters as appropriate. 4. Work with VP, Government Relations, CEO/COO and market staff to align Amerigroup with relevant community-based organizations and influential individuals in the market. 5. Organizing meetings at the state and regional levels that showcase Amerigroup programs/products and services and highlight the mission and values of Amerigroup. 6. Monitor all rule making at HHSC, TDI or any other agency where there is a possible opportunity or threat to Amerigroup business. When appropriate, lead a team to bring issues related to rule-making to resolution, including working with legal to draft responses and submit them. 7. Monitor all hearings related to relevant legislative committees. Work with VP, Government Relations and other key leader to ensure public hearings are as positive as possible for Amerigroup. 8. Continually monitor market databases and product review to analyze select opportunities. 9. Other duties as assigned or requested.

Qualifications:

EDUCATION AND EXPERIENCE: Education Required: ' Bachelor's degree Preferred: ' Advanced degree preferred. Years and Type of Experience Required: Required: ' Minimum of 10 years experience in government relations, marketing, public relations or related field and at least 5 years of leadership/management experience. Preferred ' Previous HMO/managed care industry experience preferred. ' Previous Senior Level Role in a Government Relations field. ' Experience in a Medicaid regulatory environment, state legislature or related field. Specific Technical Skills Required: ' Proficient with MS Office (Word, Excel, PowerPoint), graphics and spreadsheet applications Certifications or Licensures Required: ' None Other: Required: ' Excellent writing, communications, presentation, interpersonal, problem-solving, analytical and organizational skills. ' Excellent understanding of word processing, graphics and spreadsheet applications. ' Able to handle multiple priorities. ' Able to work well and produce high quality results under the pressure of deadlines. ' Able to work with many other resources with little supervision or direction. ' Previous HMO/managed care industry experience preferred. ' Appreciation of cultural diversity and sensitivity towards target population. SCOPE INFORMATION # Direct Reports: # Indirect Reports: 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. ' Standing and/or sitting for long periods of time. ' Data entry using repetitive motion. ' Must be able to operate a motor vehicle (in conjunction w/travel)]]> http://www.amerigroup-jobs.com/job/Atlanta-AVP-Govt-Relations-GA-30301/920172/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS http://www.amerigroup-jobs.com/job/Atlanta-AVP-Govt-Relations-GA-30301/920172/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS
Job ID: 2010-11737
# Positions: 1
Location: US-GA-Atlanta
Search Category: Health Care Operations
Type: Regular Full-Time (30+ hours)
Posted Date: 7/23/2010

More information about this job:

Overview:

Working with the Chief Medical Director, oversees medical care for AMERIGROUP products and services and oversees the health care needs of the membership. Serves as a medical manager and policy advisor to the company and health plan Chief Medical Director. 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 medical management such as provider relations, member services, benefits and claims management, etc. Assists (as determined by the plan Chief Medical Director) 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 medical management effectiveness. Reports all issues of clinical quality management to the health plan Chief Medical Director. Collaborates with the Chief Medical Director 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.

Responsibilities:

1. Responsible and accountable to the Chief Medical Director for helping to manage health plan medical costs and assuring appropriate health care delivery for AMERIGROUP health plans, products and services. Reports organizationally to the Chief Medical Director of the Health Plan; has a dotted line relationship to the Chief Medical Officer.

2. Plans, organizes, and directs the professional medical services program, consisting of all primary and specialty services for in-patient, out-patient, preventive and wellness programs.

3. Designs and implements health plan medical policies, goals and objectives.

4. Provides professional leadership and direction to the functions within the Medical Management Department (Utilization/Cost Management and Clinical Quality Management).

5. Responsible for and assists with the development of budgets, staffing plans and medical loss ratio projections, assuring the adequate allocation of resources to the medical management functions.

6. Responsible and accountable for implementing the Utilization/Cost Management Program and Clinical Quality Improvement Program.

7. Assists the Chief Medical Director with activities to promote positive community relations.

8. Assures plan conformance with legal and regulatory requirements.

9. Assists the Chief Medical Director in creating and maintaining a system that gives feedback to providers individually and collectively regarding managed care effectiveness of individual providers and networks.

10. Assists the Chief Medical Director in designing and implementing corrective action plans to address issues and improve plan and network managed care performance.

11. Collaborates with Corporate Medical Affairs and the health plan Chief Medical Director in creating and maintaining programs that incentive providers to achieve selected utilization/cost and quality outcomes.

12. Participates in policy review, performs analysis and makes recommendations.

13. Participates in the retrospective review and analysis of Plan performance from summary data of paid claims, encounters, authorization logs, compliant and grievance logs and other sources.

14. Achieves and maintains benchmarked utilization and cost management (UM) goals and clinical quality improvement (QI) objectives.

15. Provides periodic written and verbal reports and updates as required in the Quality Management Program description, the Annual Work Plan and AMERIGROUP Community Care policy and procedures to various plan committees, the health plan Chief Medical Director and Corporate Medical Affairs.

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

17. Supports pre-admission review, utilization management, and concurrent and retrospective review process.

18. Participates in risk management, claim adjudication, pharmacy utilization management, catastrophic case review, outreach programs, HEDIS reporting, site visit review coordination, triage, nutrition service review, provider orientation, credentialing, profiling, etc.

19. Conducts quality improvement and outcomes studies as directed by the state Departments of Health, the Quality Management Committee, Medical Advisory Committee, Peer Review Committee and management. Reports findings.

20. Participates in the grievance process with the Chief Medical Director, insuring a fair outcome for all members.

21. 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.

22. Participates actively in provider recruitment.

23. Assists the contracting process of providers, hospitals, ancillary providers, and emergency and other support services, and evaluates the medical aspects of provider contracts.

24. Chairs (or delegates leadership of) Advisory Committees of the health plan which include (but are not limited to) the Peer Review Subcommittee and the Credentialing Subcommittee of the Quality Management Committee.

25. Participates in key marketing activities and presentations.

26. Promotes wellness and ensures programs of prevention, education and outreach to members and providers consistent with AMERIGROUP's mission, vision and values.

27. Maintains up-to-date knowledge of new information and technologies in medicine and their application to the AMERIGROUP health plan.

28. Performs and oversees in-service staff training and education of professional staff.

29. Represents AMERIGROUP at medical group meetings, conferences, etc.

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

31. Participates in key marketing activities and presentations, as necessary, to assist the marketing effort.

32. Ensures that the Utilization Management Program is available on a 24 hour basis to respond to authorization requests for emergency and urgent services and is available, at a minimum, during normal working hours for inquiries and authorization requests for non-urgent health care services.

33. The Associate Medical Director must ensure that a covered person enrolled in the Plan is permitted to: a. choose or change a primary care physician from among participating providers in the provider network; and b. when appropriate, choose a specialist from among participating network providers following an authorized referral, if required by the carrier, and subject to the ability of the specialist to accept new patients.

34. Performs other duties as requested or assigned.

Qualifications:

EDUCATION AND EXPERIENCE:

Education

Required: Continuing education to remain current in medical and management areas.

Preferred: Masters in Public Health, MBA, or MA preferred

Years and Type of Experience Required:

Required: 5 years of clinical experience in the practice of medicine, 2 of which have been in medical and/or health administration. 3 years of management and/or clinical experience in a managed care environment.

Certifications or Licensure

Required: Must be licensed in the Plan State as a Doctor of Medicine or a Doctor of Osteopathy. 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.

Other Any equivalent combination of education and experience.

Required:

- Management skills to meet the organizational goals.

- Must possess excellent communications skills to interface with providers, staff, and management.

- Knowledge of medical, 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]]> http://www.amerigroup-jobs.com/job/Atlanta-Associate-Medical-Director-Plan-Job-GA-30301/886508/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS http://www.amerigroup-jobs.com/job/Atlanta-Associate-Medical-Director-Plan-Job-GA-30301/886508/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS
Job ID: 2010-11788
# Positions: 1
Location: US-GA-Atlanta
Search Category: Health Care Operations
Type: Regular Full-Time (30+ hours)
Posted Date: 7/23/2010

More information about this job:

Overview:

The AVP of Quality Management provides leadership in the development, coordination, implementation, and evaluation of the continuous quality improvement initiatives throughout the company in the areas of quality of care, quality of service, and provider/member satisfaction. Provides direction, leadership and education for compliance with NCQA standards to achieve and maintain NCQA accreditation. Maintains liaison with state and federal regulatory agencies. Supports health plan coordination of the quality management program across the company by sharing replicable technology, benchmarking, and best practices. Works to establish and promote a culture of organizational excellence.

Responsibilities:

1. Directs and provides leadership for implementing, monitoring and evaluating the Quality Management Program for the health plan ensuring the demographic and epidemiological needs of the population served are met.

2. Establishes objectives and annual goals in conjunction with the CEO and Medical Directors.

3. Oversees implementation and evaluation of the scope of the quality management program.

4. Promotes plan-wide understanding, communication, and coordination of the quality management program.

5. Directs and provides leadership for Plan compliance with NCQA standards.

6. Provides leadership for the interpretation of results and development of improvement action plans arising from provider and member satisfaction surveys.

7. Serves as a resource for design of quality improvement studies, indicators, data collection, and data trend analysis/interpretation.

8. Provides leadership in developing, monitoring, and evaluating HEDIS improvement action plans.

9. Participates in market development activities through due diligence activities.

10. Provides leadership for health plan QM activities through sharing of replicable technology/benchmarking/best practices, assisting with review preparation, and providing guidance in quality improvement activities.

11. Provides coaching for development of QM personnel.

12. Works to establish and promote organizational excellence throughout the health plans.

13. Monitors compliance with State and Federal quality improvement/assurance requirements.

14. Evaluates and makes recommendations for oversight of delegated services.

15. Develops the QM department annual operating and capital budgets to sufficiently meet departmental needs, and ensures the department stays within budget, and accounts for variances.

16. Interviews, manages, evaluates, and develops new and existing departmental staff.

17. Recognizes and utilizes appropriate channels for communication, encourages two-way communication, and encourages staff to participate in creative program development.

18. Effectively communicates information to superiors, team members, and other appropriate staff in a timely, accurate, and courteous manner.

19. Provides leadership/facilitation for groups as needed.

20. Represents Quality Management through group presentations on various topics for a variety of internal and external audiences.

21. Other duties as assigned.

Qualifications:

EDUCATION AND EXPERIENCE:

Education

Required:Bachelor Degree

Preferred: MSN, MPH, MPA

Years and Type of Experience Required:

Required:

- Minimum of 10 years experience in quality management, quality improvement, risk management, and/or utilization review in HMO setting and 5 years of leadership/management experience.
- Previous NCQA accreditation and HEDIS reporting experience required.

Specific Technical Skills

Required: Knowledge of basic computers including word processing and spreadsheets.

Preferred: Knowledge of data base applications.

Certifications or Licensure

Preferred:

- Current RN state license (or as required by Plan)
- CPHQ

Other

- Strong knowledge base in areas of quality improvement, accreditation, HEDIS, satisfactory survey process, and organizational improvement.
- Excellent written and verbal communication skills.
- Ability to work effectively with physicians and other health care providers as well as with multi-disciplinary teams across department lines.
- Excellent problem solving skills.
- Demonstrates strong organizational skills.
- Strong leadership, coaching, and staff development skills
- Ability to develop and give presentations and to facilitate groups.
- Ability to handle multiple tasks.
- Appreciation of cultural diversity and sensitivity towards target population.

SCOPE INFORMATION

- # Direct Reports: Will likely have direct reports.
- # Indirect Reports: Will likely have indirect reports.
- Budgetary $ Responsibility: May have budgetary responsibility.

PHYSICAL REQUIREMENTS

Must be able to operate a computer.

Must be able to operate a phone.

Must be able to travel on common carriers and to adhere to AMERIGROUP's travel policies]]> http://www.amerigroup-jobs.com/job/Atlanta-AVP-Quality-Management-Plan-Job-GA-30301/886520/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS http://www.amerigroup-jobs.com/job/Atlanta-AVP-Quality-Management-Plan-Job-GA-30301/886520/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS
Job ID: 2010-11829
# Positions: 1
Location: US-GA-Atlanta
Search Category: Nursing
Type: Regular Full-Time (30+ hours)
Posted Date: 7/23/2010

More information about this job:

Overview:

Support the development and implementation of quality improvement interventions and audits and assists in resolving deficiencies that impact on plan compliance to regulatory and accreditation standards. Assignments are somewhat broad in nature, often requiring creativity and originality. Review appeals/grievances/quality of care issues received in the Quality Management Department requiring assessment of medical records or clinical information to ensure appropriate processing. Analyze the appeal/grievances/quality of care submission, AMISYS/FACET, CAT database, and clinical resources to ensure that the issue is appropriately processed. Assures documentation of the appeal/grievance/quality of care is appropriate, systems are updated to reflect the issue and that the appeal/grievance/quality of care are routed appropriately. Generate letters to providers/appellants to document appeal/grievance/quality of care documentation requests/outcomes are appropriate.

Responsibilities:

1. Investigate and research, gather information, send appeal to Medical Director/ like specialty and resolve appeals with letter generation within standard time frames.

2. Assist in implementation and monitoring of quality studies including, but not limited to the development and implementation of preventive health and chronic disease outcomes improvement interventions such as newsletter article, member education and outreach interventions, provider education and outreach interventions, medical record review, focus studies and surveys

3. Participate and contribute to external reviews site visits preparations by the State, accreditation review, Medical Advisory Committee, and Quality Management Committee

4. Conduct internal monitoring and auditing timeline compliance standards. Assist in action plan/interventions as needed with management

5. Research and summarize credentialing files for Committee review, as assigned

6. Process, track and trend, and report medical necessity appeals, grievances, and quality of care issues by line of business for compliance and review

7. Coordinate with departments including Member Services, Provider Relations, Credentialing, Pharmacy and Claims to resolve provider and member issues related to appeals, grievances, and quality of care issues

8. Organize and prioritize clinical job tasks in order of importance and impact on members and providers

9. Investigate and resolves governmental agency and executive level inquiries/issues

10. Prepare medical files for Appeal Committee, Peer Review Committee, and Fair Hearings

11. Perform monthly, quarterly, annual and ad hoc medial record reviews, as assigned

12. Utilize leadership skills and serves as a subject matter expert for appeals/grievances/quality of care issues and is a resource for clinical and non clinical team members in expediting the resolution of outstanding issues

13. Actively participates in quarterly Plan HIPAA audits

14. Maintains member confidentiality and follow HIPAA guidelines

15. Completes special projects or assignments as needed to meet initiatives and/or objectives of the department

16. Review claims/appeals requiring authorization and/or coding review routed to the department for medical necessity and appropriateness based on approved criteria

17. Process and document claims/appeals in compliance with department standard and state regulations

18. Maintains accurate reporting to assure compliance with departmental standards and policies

19. Adhere to company and department policies and procedures related to claims payment, authorization decisions, and overturn/denial decisions related to appeals

Qualifications:

Education

Required: Vocational Nursing diploma or A.A. in Nursing

Preferred: BSN

Years and Type of Experience Required:

Required: 3 years of clinical experience

Preferred: 3-5 years in a managed care environment or related field. Demonstrate leadership, strong communication skills

Certifications or Licensure

Required: Valid Registered Nurse or Licensed Practical Nurse license

Other

Required:

- Ability to work on multiple projects and tasks on a daily basis; strong presentation/verbal/writing/listening skills;
- Ability and confidence to make decisions based on the scope of the job;
- Ability to travel within the State
- Computer literate including word processing and spreadsheet knowledge
- Excellent verbal and written communication skills
- Demonstrate strong decision-making skills
- Ability to work independently and in groups effectively
- Appreciation of cultural diversity and sensitivity towards target populations

PHYSICAL REQUIREMENTS: The physical requirements described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

- Must be able to operate a computer.
- Must be able to operate a telephone]]> http://www.amerigroup-jobs.com/job/Atlanta-Quality-Operations-Nurse-Job-GA-30301/886537/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS http://www.amerigroup-jobs.com/job/Atlanta-Quality-Operations-Nurse-Job-GA-30301/886537/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS
Job ID: 2010-11881
# Positions: 1
Location: US-GA-Atlanta
Search Category: Health Care Operations
Type: Regular Full-Time (30+ hours)
Posted Date: 7/23/2010

More information about this job:

Overview:

Responsible for providing direction and support for regional office, network expansion, network acquisition integration initiatives, marketing, provider relations and other support activities as assigned, typically supporting an entire region. Leads a team of professionals consisting of subordinate Manager(s) and associates to carry out objectives in achieve marketing, growth, servicing and financial goals for an assigned region or market.

Responsibilities:

1. Directs new market network development, network expansion, and network acquisition initiatives as well as basic development and execution of provider network development strategies; manages medical management team and coordinate marketing efforts in conjuction with region headquarters in an entire region.

2. Accountable for subordinate(s) development and performance.

3. Responsible for development of relations and negotiations with providers; provider organizations and community leaders to ensure ongoing servicing and education.

4. Responsible for coordination of interdepartmental network development and implementation processes and manages project plans as well as account management and ongoing servicing and education of provider network.

5. Directs basic new market, provider network and provider research and analyses. Prepares network recommendations and projections.

6. Provides direction and oversight for medical management within the region

7. Travel extensively to accomplish network development, marketing goals and any other assignments.

8. Oversee Community Relations, Marketing, Medical Management and Office Management.

10. Responsible for ensuring quality care, improved outcomes and effective management of healthcare resources. Activities include staffing, policy decisions, operational issues and external relationship development within the region.

9. Other duties as assigned.

Qualifications:

EDUCATION AND EXPERIENCE:

- Bachelor's degree in business administration, healthcare administration or a related field, or minimum of eight (8) years related experience working in managed care, network development and provider relations.

- Experience with project management is preferred.

- An understanding of the healthcare industry, managed care and Provider financing and Medicaid reimbursement is preferred.

- Experience in contracting with hospitals and hospital systems preferred.

- Provider Servicing and Education

- Marketing and Community Relations

- Medical Management

Scope Information:

- Coordinates the region's annual administrative, medical, and capital budget process.

- Manages the regions monthly reporting and review of financials/accruals.

- Oversees a staff of 24 associates with two direct reports.

CERTIFICATION AND LICENSURE:

- Current driver's license, and at minimum, state required amount of automobile insurance for state where automobile is licensed.

Knowledge and Skills

- Ability to successfully interact with community healthcare clinical professionals and business executives nationwide.

- Self starter and /goal oriented.

- Computational and analytical skills.

- Respect for, and ability to work well with all levels within the organization and within the Providerprovider community.

- Appreciation of cultural diversity and strong sensitivity towards the target member population.

- Excellent communication, and organizational and management skills.

- Ability to prioritize and execute multiple complex projects in various markets simultaneously.

- Ability to complete projects/assignments accurately, on-time, on-budget and with moderate supervision.

PHYSICAL REQUIREMENTS

- Must be able to travel on common carriers, drive an automobile and adhere to AMERIGROUP's travel policy.

- Must be able to operate a computer, telephone and other commonly used business-related items]]> http://www.amerigroup-jobs.com/job/Atlanta-Director,-Regional-Ops-Job-GA-30301/886552/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS http://www.amerigroup-jobs.com/job/Atlanta-Director,-Regional-Ops-Job-GA-30301/886552/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS
Job ID: 2010-11944
# Positions: 1
Location: US-GA-Atlanta
Search Category: Sales & Marketing
Type: Regular Full-Time (30+ hours)
Posted Date: 7/23/2010

More information about this job:

Overview:

Responsible for servicing external contacts and provide outreach to members as assigned.

Responsibilities:

1. Acts as service representative for assigned projects and acts as a resource to the membership and the community as needed

2. Assist with establishing and maintaining positive relationships with community organizations, provider offices, faith based organizations and perform other activities to enhance Amerigroup's presence in the community.

3. Conducts presentations, staff exhibits and perform other activities in an effort to maintain and established positive relationships with providers, community and faith based organizations.

4. Identify and collect educational material on community networks and advocacy groups with similar missions and values and communicate the information to management within a timely manner.

5. Provides telephonic assistance, outreach and/or guidance to members and potential members regarding benefit and enrollment questions, and/or providing assistance on any social service needs.

6. When appropriate and approved by the State, assists potential and existing members with the enrollment or recertification process.

7. Supports health education activities and referral of members to health education programs.

8. Represents Amerigroup at community organizations and events such as promotions, enrollment events (when approved by the State) and health fairs.

9. Identifies cultural issues regarding current and potential members and communicates those issues and concerns to management on a timely manner

10. Assists with retention activities necessary to ensure resolution to members and potential members around continuity of care issues. 1

1. Meets and/or exceeds department service standards.

12. All other professional duties as assigned.

Qualifications:

EDUCATION AND EXPERIENCE:

Education

Required:

- High School

Preferred:

- Associates Degree or BS/BA degree

Years and Type of Experience Required:

Required:

- 1 yr experience in healthcare or sales/marketing environment, if highest education level is High School.

Specific Technical Skills

Preferred:

- Experience working with excel and word

Certifications or Licensure Required:

- Must possess a valid drivers license and have access to a motor vehicle and must possess valid motor vehicle insurance

PHYSICAL REQUIREMENTS

- Must be able to operate a computer
- Must be able to operate a telephone
- Must be able to operate a motor vehicl]]> http://www.amerigroup-jobs.com/job/Atlanta-Marketing-Rep-(I)-Plan-Job-GA-30301/886581/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS http://www.amerigroup-jobs.com/job/Atlanta-Marketing-Rep-(I)-Plan-Job-GA-30301/886581/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS