http://www.amerigroup-jobs.com/go/Albuquerque-Healthcare-Administration-Jobs/168897/ View Albuquerque Healthcare Administration Jobs at Amerigroup Wed, 08 Sep 2010 02:09:20 GMT en-us /sites/amerigroup/images/banner.gif http://www.amerigroup-jobs.com/go/Albuquerque-Healthcare-Administration-Jobs/168897/ 720
Job ID: 2010-12061
# Positions: 1
Location: US-NM-Albuquerque
Search Category: Health Care Operations
Type: Regular Full-Time (30+ hours)
Posted Date: 8/2/2010

More information about this job:

Overview:

JOB SUMMARY:

Serves as liaison to providers (including physicians, hospitals, and/or ancillary providers) and internal departments at the health plan.

Responsible for performing activities designed to establish and maintain positive and productive relationships with AMERIGROUP network providers for Medicaid and Medicare products.

These activities include responding to inquiries from providers regarding benefits, claim resolution, appeal status, and authorization or referral information.

Also may be responsible for recruiting providers to ensure network access and service adequacy.

Provides training, guidance and assistance to Provider Relations Representatives I to support their skill development and successful completion of assignments.

May perform position requirements in the field or telephonically, as appropriate.

More emphasis is placed on field work at the Rep Level II.

Responsibilities:

PRIMARY RESPONSIBILITIES:

1. 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).

2. Ensures that provider relationships with the Plan are positive and productive for both parties.

3. 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.

4. Assists 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.

5. Collaborates with local and corporate staff as necessary to ensure that appropriate applications are processed, contracts are executed and all providers are credentialed in a timely manner.

6. Analyzes provider network for adequacy in addressing members' medical needs and assists in the identification and recruitment of key providers where network gaps or needs exist.

7. Creates and maintains information required to support the network development process.

8. Develops training materials and conducts on-site provider education, orientations, and provider servicing visits to ensure providers are well-acquainted with AMERIGROUP benefits, policies, and procedures.

9. Provides expertise and assistance relative to provider billing and payment guidelines consistent with AMERIGROUP policies and procedures.

10. Provides follow up and intervention relating to provider complaints, thereby ensuring that the complaint process is appropriately handled within established time frames.

11. Participates in standing meetings, as necessary, regarding provider reimbursement issues and network development activities.

12. Performs other duties and special projects as assigned

Qualifications:

EDUCATION AND EXPERIENCE:

Education Required: BA/BS degree or equivalent experience

Years and Type of Experience Required: Required: 5+ years of managed care experience, preferably in a Medicaid environment

Specific Technical Skills Required:

Proficiency with Microsoft computer applications including Outlook, Word, and Excel.

Claims experience/knowledge of medical coding

Strong telephonic and customer service skills.

Effective presentation skills.

Preferred: Experience using Sales force CRM; Experience using Facets.

Certifications or Licensures Required: Valid Drivers License

Other:

Required:

Excellent verbal and written communication skills.

Detail-oriented.

Ability to handle multiple tasks in a fast-paced environment.

Must be service oriented and able to identify and resolve problems.

Appreciation of cultural diversity and sensitivity toward target population.

SCOPE INFORMATION

# Direct Reports:

# Indirect Reports:

Budgetary $ Responsibility:

PHYSICAL REQUIREMENTS

Must be able to operate a computer, telephone and fax machine.

Must be able to travel locally.

Must be able to operate a motor vehicle.

Must be able to conduct and participate in meetings]]> http://www.amerigroup-jobs.com/job/Albuquerque-Provider-Relations-Rep-II-Job-NM-87101/893090/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS http://www.amerigroup-jobs.com/job/Albuquerque-Provider-Relations-Rep-II-Job-NM-87101/893090/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS
Job ID: 2010-12259
# Positions: 1
Location: US-NM-Albuquerque
Search Category: Nursing
Type: Regular Full-Time (30+ hours)
Posted Date: 8/27/2010

More information about this job:

Overview:

JOB SUMMARY:

Performs technical and administrative work required to evaluate the necessity, appropriateness and efficiency of the use of medical services procedures and facilities. Licensed RN responsible for clinical review of all acute and subacute services for appropriateness based on medical criteria.

This individual is responsible for the management of healthcare resources necessary and appropriate for achievement of desired acute and subacute outcomes and the coordination of alternative levels of care for membership.

Responsibilities:

PRIMARY RESPONSIBILITIES:

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

2. Predicts and plans for patient's needs from pre-admission, through acute and subacute 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. Strives to maintain quality care while effectively utilizing resources.

7. Identifies and reports any quality or utilization issues to the Medical Director.

8. 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.

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

10. Participates in rounds with the Medical Director.

11. Review Plan appeal items for concurrent and retrospective reviews as required and requested.

12. Monitors and facilities appropriate utilization of resources utilizing clinical criteria.

13. Tracks and reports trends of inappropriate utilization of resources to the Medical Director.

14. Participates in a multi-disciplinary clinical team to achieve positive member outcomes.

15. Functions as a resource to the clinical team regarding approved criteria, practice guidelines and alternative treatment options.

16. Utilizes effective communication, conflict management and negotiation skills.

17. Utilizes excellent customer service principles to assist internal and external customers.

18. Participates in Quality Improvement Process.

19. Maintains member confidentiality.

20. Other duties as requested or assigned.

Qualifications:

EDUCATION AND EXPERIENCE:

Education

Required: Nursing Diploma

Preferred: Bachelor's or Master's Degree

Years and Type of Experience Required:

Required:

Two years of Utilization Management or Hospital/Acute care experience required.

Currently licensed RN with 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 preferred.

Preferred:

Specific Technical Skills

Required: Advance Computer Literacy

Preferred:

Certifications or Licensure

Required: Current State RN license

Preferred: Certified Professional Utilization Review; Certified Case Managers a plus.

Must possess a valid driver's license, auto insurance and access to a motor vehicle.

Preferred:

Other Required:

Computer literate.

Excellent verbal and written communications skills.

Strong decision making skills.

Ability to provide services in an environment that involves multiple health care systems.

Ability to interact with all relevant components of the health care system.

Ability to provide services that deal with the individual's broad spectrum of needs.

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

Appreciation of cultural diversity and sensitivity towards target population.

Bilingual a plus.

Preferred:

SCOPE INFORMATION Item Measure

# Direct Reports 0

# Indirect Reports 0

Budgetary $ Responsibility N/A

PHYSICAL REQUIREMENTS:

Must be able to operate a computer.

Must be able to operate a telephone.

Must be able to sit for long periods of time.

Must be able to operate a motor vehicle and travel locally (as required by Plan)]]> http://www.amerigroup-jobs.com/job/Albuquerque-Utilization-Manager-RN-NM-87101/920951/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS http://www.amerigroup-jobs.com/job/Albuquerque-Utilization-Manager-RN-NM-87101/920951/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS
Job ID: 2010-12138
# Positions: 1
Location: US-NM-Albuquerque
Search Category: Nursing
Type: Regular Full-Time (30+ hours)
Posted Date: 8/13/2010

More information about this job:

Overview:

The Manager of Quality Management - RN is responsible in conjunction with the Director of QM, the Medical Director and the CEO and COO for developing, coordinating, and implementing quality initiatives within the health plan.

The Manager of QM - RN will provide 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.

The Manager of QM - RN will 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 Director of QM, the Plan Medical Director and CEO and COO.
2. In conjunction with the Director of QM, 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 team?s performance and ensure adherence to department?s 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: Strong preference for Bachelors or Masters 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

- Minimum 1 year management/leadership experience.

Preferred:

- Previous NCQA accreditation and HEDIS reporting experience strongly preferred

- Experience with the urban Medicaid population preferred
- Bilingual (speak, read, write) Spanish - 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.
- Advanced competencies in the Microsoft Office products
- 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

PHYSICAL REQUIREMENTS

- Must be able to operate a computer.
- Must be able to operate a telephone]]> http://www.amerigroup-jobs.com/job/Albuquerque-Mgr-Quality-Mgmt-RN-Plan-Job-NM-87101/908001/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS http://www.amerigroup-jobs.com/job/Albuquerque-Mgr-Quality-Mgmt-RN-Plan-Job-NM-87101/908001/?utm_source=J2WRSS&utm_medium=rss&utm_campaign=J2W%5FRSS