Amerigroup Corporation - Norfolk, Virginia Area
Provide clinical leadership and expertise to the development and implementation of national programs designed to assure members receive appropriate and timely access to health care services in a cost effective manner. Under the direction of the National Medical Director, provide clinical support to the Reimbursement Policy Management Department, Clinical Operations Department, Pharmacy Department and other Amerigroup departments as assigned. Work collaboratively with HCMS and other Amerigroup departments to achieve overall organizational goals and objectives.
- Shares responsibility for managing medical costs, executing Medical Expense Initiatives (MEIs) and assuring appropriate health care delivery and reimbursement for Amerigroup health plans, products and services.
- Supports the design and implementation of Amerigroup pharmacy, medical, concurrent review, precertification, and provider reimbursement programs and policies.
- Provides clinical expertise to the Pharmacy Department
- Co-lead, with SVP of Pharmacy or designee, the development and implementation of a comprehensive Medication Therapy Management Program as well as other clinical strategies and monitor the clinical effectiveness.
- Co-lead, with SVP of Pharmacy or designee, the development and implementation of a comprehensive medical/pharmacy specialty injectable strategy.
- Co-chair P&T Committee and participate in formulary coverage assessment and decisions.
- Provides clinical expertise to the Reimbursement Policy Management Department including:
- Participates in the review and resolution of provider reimbursement disputes.
- Provides clinical oversight of hospital audits
- Provide clinical input into the assessment of quarterly and annual new code updates including recommendations for coverage and precertification
- Participate in Coding Committee and other coding projects as assigned (i.e. ICD-10).
- In conjunction with Healthcare Economics, CID, and Reimbursement Policy departments, utilizes clinical expertise to evaluate and remediate potential areas of fraud, waste, abuse, and aberrant billing patterns identified through data mining.
- Provides clinical expertise to Clinical Operations department and other Amerigroup departments, both health plan and corporate, as assigned.
- Identifies and provides educational opportunities for pharmacist, nursing, and coding staff.
Desired Skills & Experience
EDUCATION AND EXPERIENCE:
• Medical Degree (M.D. or D.O)
• Masters in Public Health, MBA or MA or equivalent experience
Years and Type of Experience Required:
• Five years of clinical experience in the practice of medicine and continued maintenance of clinical knowledge.
• Minimum of three years of management and /or utilization management in a managed care environment.
Years and Type of Experience Preferred:
• Experience in provider reimbursement, medical coding, fraud waste and abuse prevention, and/or pharmacy benefit management
Specific Technical Skills Required:
• Proficient in MS Office (MS Word, Excel, Outlook, PowerPoint)
Certifications or Licensures Required:
• Unencumbered, active medical license
• Current board certification
• Ability to meet Amerigroup credentialing requirements
• 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.
SCOPE INFORMATION # Direct Reports: 0-3
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
Managing health care is more than a business for Amerigroup, it is a passion. Amerigroup is a Fortune 500 Company and the leading publicly-traded company dedicated exclusively to caring for the medically vulnerable, seniors, and persons with disabilities through publicly-funded programs. For 15 years, Amerigroup has been involved in developing Real Solutions for its members, in addition to offering health programs for Medicaid and Medicare populations. Amerigroup serves approximately 1.9 million Americans with health plans located in 11 states. Amerigroup Mission Our mission is to improve the health of Americans, one person at a time. As a company, Amerigroup showcases our mission through Real Solutions in healthcare, and emphasizing corporate ethical responsibility. "Until every person in America has access to a physician through an organized system of care, our job is not finished." Amerigroup's Real Solutions 1.We improve health outcomes. 2.We save taxpayer money. 3.We expand access to care. 4.We provide innovative solutions to states, providers and members. 5.We reduce premature deliveries and infant mortalities. 6.We improve overall child health. 7.We help seniors and people with disabilities live more independent, healthier lives. 8.We make it easier for doctors to do their jobs. 9.We keep medical costs low, while maintaining quality care. 10.We provide a reasonable return for our investors.
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