Amerihealth

Amerihealth Raleigh, NC, USA
Sep 19, 2019
Full time
Job Brief RN responsible for completing medical necessity reviews. Your career starts now. We re looking for the next generation of health care leaders. At AmeriHealth Caritas, we re passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we d like to hear from you. Headquartered in Philadelphia, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at . Responsibilties: Under the direction of the unit Supervisor, the Clinical Care Reviewer is responsible for completing medical necessity reviews. Using clinical knowledge and nursing experience, the nurse reviews provider requests for inpatient and outpatient services, working closely with members and providers to collect all information necessary to perform a thorough medical necessity review. It is within the nurse s discretion to pend requests for additional information and/or request clarification. The nurse will use his/her professional judgment to evaluate the request to ensure that appropriate services are approved and recognize care coordination opportunities and refer those cases as needed. The nurse will apply medical health benefit policy and medical management guidelines to authorize services and appropriately identify and refer requests to the Medical Director when guidelines are not met. The nurse will maintain current knowledge and understanding of the laws, regulations, and policies that pertain to the organizational unit s business and uses clinical judgment in their application. Experience and education: 3 or more years experience in a related clinical setting preferred Registered Nurse graduated from an accredited RN program Current unrestricted Registered Nurse license. Valid Driver s License and reliable automobile transportation for on-site assignments and off-site work related activities. #SP1 Back Share Apply Now Associated topics: antibody, biopharma, diet, dietician, drug development, injury, kinesiology, medical, nutritionist, transfection
Amerihealth Greenville, NC, USA
Sep 17, 2019
Full time
Job Brief Responsible for building, nurturing and maintaining positive working relationships between Plan and its contracted providers Your career starts now. We're looking for the next generation of health care leaders. At AmeriHealth Caritas, we're passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we'd like to hear from you. Headquartered in Philadelphia, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at . Responsibilites: The Account Executive I (AE I) is responsible for building, nurturing and maintaining positive working relationships between Plan and its contracted providers. Assigned provider accounts may include single or multiple practices in single or multiple locations, integrated delivery systems or other provider organizations. AE I maintains in depth understanding of Plan's contracts and provider performance and needs, identifying, developing and conducting relevant and tailored provider orientation sessions, making educational visits and working to resolve provider issues. Responsible for monitoring and managing provider network by assuring appropriate access to services throughout the Plan's territory in keeping w/ State and Federal contact mandates for all products. Identifies, contacts and actively solicits qualified providers to participate in Plan at new and existing service areas and products, assuring financial integrity of the Plan is maintained and contract management requirements are adhered to, including language, terms and reimbursement requirements. Maintains complete understanding of Plan reports and metrics and uses them to evaluate the performance of assigned providers/practices/facilities, determining, communicating and implementing plans for providers to improve performance and measuring ongoing performance. Uses data to develop and implement methods to improve relationships. Assists in corrective actions required up to and including termination, following Plan policies and procedures. Supports the Quality Management department with the credentialing and re-credentialing processes, investigation of member complaints and any potential quality issues. Maintains a functional working knowledge of Facets, including the provider database and routinely relays information about additions, deletions or corrections to the Provider Maintenance Department. Maintains and delivers accurate, timely activity and metric reports as required. Identifies and maintains strong partnerships with appropriate internal resources and stakeholders. Experience/Education: Medicaid experience preferred. Demonstrated strength in working independently, establishing influential relationships internally and externally. Meeting and facilitation skills, priority setting and problem solving skills. Three to five years experience in the managed care health insurance industry. Experience with providers across the state of North Carolina Willingness to travel within the state (50%) Bachelor's degree preferred. This position will work from home and will travel throughout Region 6 and part of Region 5 Which is the East side of the state. Coverage along the coast as well. #SP2 Back Share Apply Now
Amerihealth Southfield, MI, USA
Sep 16, 2019
Full time
Job Brief Market President for Blue Cross Complete, Southfield MI Your career starts now. We're looking for the next generation of health care leaders. At AmeriHealth Caritas, we're passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we'd like to hear from you. Headquartered in Philadelphia, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at . Blue Cross Complete of Michigan is contracted by the state of Michigan to provide medical services to eligible Medicaid and Healthy Michigan Plan beneficiaries in 32 counties. Blue Cross Complete of Michigan is an independent licensee of the Blue Cross and Blue Shield Association. Our mission and values We help people get care, stay well and build healthy communities. We have a special concern for those who are poor. Our values: Advocacy, care of the poor, compassion, competence, dignity, diversity, hospitality and stewardship. Our history Blue Cross Complete of Michigan, LLC, has served Medicaid-eligible residents in Livingston, Washtenaw and Wayne counties since 2007. In January 2016, our service area expanded to include 29 additional counties. The Market President will provide the strategic vision and operational expertise to successfully lead the Blue Cross Complete (BCC) Health Plan. In this role, the Market President will be a proactive, strategic, and decisive leader who demonstrates a commitment to ensuring that our members have access to high quality health care services. The Market President is responsible for cultivating AmeriHealth Caritas' presence and brand recognition through establishing influential relationships with key stakeholders and by developing partnerships with key providers, associations, and community leaders. Relationship development with the state's Medicaid agency is essential. The Market President will lead the effective and efficient operations of this Health Plan directly and/or indirectly overseeing Medical Affairs, Provider Network Management, Provider Network Operations, Quality, Population Health, Marketing and/or Community Outreach, Compliance and Regulatory Affairs, Community Investment and Legislative affairs, HR, Finance and Information Services. In collaboration with these corporate and regional stakeholders, this executive will lead the strategic development, growth, and operations of the health plan starting with capture planning and RFP response development. The Market President will demonstrate a deep understanding of the defined state's Medicaid market and possess the qualities that support our core values and mission which will result in successful achievement of financial, membership, and plan goals. Key Responsibilities The Market President that leads the AmeriHealth Caritas Health Plan will: * Formulate and implement business plans and strategies to ensure profitable operations, meet short-term objectives, and support long-term growth, success, and competitive position in the market. * Be accountable for full profit and loss responsibility and develop and implement adequate measures to meet the fiscal needs of the company and maintain an effective system of budgetary control. * Monitor and analyze the changing Medicaid landscape and recommend programs and policies to proactively address the changing needs of the membership. * Identify State and/or product-specific priorities and determine the appropriate strategic approach that will drive business growth and differentiate AmeriHealth Caritas in the marketplace. * Work collaboratively with Enterprise Operations to ensure all back office functions are exceeding the requirements of the relevant contract(s). * Strive to ensure the overall level of quality for delivery of medical services meets or exceeds appropriate industry standards. * Provide personal leadership that encourages employee productivity and responsiveness to the needs of current and prospective members, providers, and other community and regulatory customers. * Ensure programs are established and monitored to comply with all relevant federal, State, and other local regulations. * Foster and builds a collaborative partnership with a cross functional internal team and external constituents/stakeholders. * Build a best-in-class team that reflects the AmeriHealth Caritas culture and supports the line of business. * Ability to collaborate, navigate and work in a complex matrixed reporting environment. Education/Experience: * Bachelor's Degree (BA/BS Business or related/Health Care Industry * Master's Degree preferred. * Clinical background beneficial, but not required. * 5-10 years of operational experience in Medicaid/Medicare/LTSS * 10 or more years' progressive responsibility in Business or Government, health care management experience required; previous experience in a health plan leadership role preferred. * Credibility, knowledge, and experience working within the state we are awarded strongly preferred. * Demonstrated knowledge and experience in a leadership role in corporate or health plan operations including enrollment, member services, provider relations, regulatory compliance, contract negotiations, quality, government relations, and medical management strongly preferred. * Experience working in a matrixed environment strongly preferred. Understands how to collaborate, navigate and work within a structure with many direct and indirect reporting relationships; while still being the one accountable for the overall P&L of the plan. #SP1 Back Share * * * * * Apply Now
Amerihealth Southfield, MI, USA
Sep 16, 2019
Full time
Job Brief Market President for Blue Cross Complete, Southfield MI Your career starts now. We're looking for the next generation of health care leaders. At AmeriHealth Caritas, we're passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we'd like to hear from you. Headquartered in Philadelphia, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at . Blue Cross Complete of Michigan is contracted by the state of Michigan to provide medical services to eligible Medicaid and Healthy Michigan Plan beneficiaries in 32 counties. Blue Cross Complete of Michigan is an independent licensee of the Blue Cross and Blue Shield Association. Our mission and values We help people get care, stay well and build healthy communities. We have a special concern for those who are poor. Our values: Advocacy, care of the poor, compassion, competence, dignity, diversity, hospitality and stewardship. Our history Blue Cross Complete of Michigan, LLC, has served Medicaid-eligible residents in Livingston, Washtenaw and Wayne counties since 2007. In January 2016, our service area expanded to include 29 additional counties. The Market President will provide the strategic vision and operational expertise to successfully lead the Blue Cross Complete (BCC) Health Plan. In this role, the Market President will be a proactive, strategic, and decisive leader who demonstrates a commitment to ensuring that our members have access to high quality health care services. The Market President is responsible for cultivating AmeriHealth Caritas' presence and brand recognition through establishing influential relationships with key stakeholders and by developing partnerships with key providers, associations, and community leaders. Relationship development with the state's Medicaid agency is essential. The Market President will lead the effective and efficient operations of this Health Plan directly and/or indirectly overseeing Medical Affairs, Provider Network Management, Provider Network Operations, Quality, Population Health, Marketing and/or Community Outreach, Compliance and Regulatory Affairs, Community Investment and Legislative affairs, HR, Finance and Information Services. In collaboration with these corporate and regional stakeholders, this executive will lead the strategic development, growth, and operations of the health plan starting with capture planning and RFP response development. The Market President will demonstrate a deep understanding of the defined state's Medicaid market and possess the qualities that support our core values and mission which will result in successful achievement of financial, membership, and plan goals. Key Responsibilities The Market President that leads the AmeriHealth Caritas Health Plan will: Formulate and implement business plans and strategies to ensure profitable operations, meet short-term objectives, and support long-term growth, success, and competitive position in the market. Be accountable for full profit and loss responsibility and develop and implement adequate measures to meet the fiscal needs of the company and maintain an effective system of budgetary control. Monitor and analyze the changing Medicaid landscape and recommend programs and policies to proactively address the changing needs of the membership. Identify State and/or product-specific priorities and determine the appropriate strategic approach that will drive business growth and differentiate AmeriHealth Caritas in the marketplace. Work collaboratively with Enterprise Operations to ensure all back office functions are exceeding the requirements of the relevant contract(s). Strive to ensure the overall level of quality for delivery of medical services meets or exceeds appropriate industry standards. Provide personal leadership that encourages employee productivity and responsiveness to the needs of current and prospective members, providers, and other community and regulatory customers. Ensure programs are established and monitored to comply with all relevant federal, State, and other local regulations. Foster and builds a collaborative partnership with a cross functional internal team and external constituents/stakeholders. Build a best-in-class team that reflects the AmeriHealth Caritas culture and supports the line of business. Ability to collaborate, navigate and work in a complex matrixed reporting environment. Education/Experience: Bachelor's Degree (BA/BS Business or related/Health Care Industry Master's Degree preferred. Clinical background beneficial, but not required. 5-10 years of operational experience in Medicaid/Medicare/LTSS 10 or more years' progressive responsibility in Business or Government, health care management experience required; previous experience in a health plan leadership role preferred. Credibility, knowledge, and experience working within the state we are awarded strongly preferred. Demonstrated knowledge and experience in a leadership role in corporate or health plan operations including enrollment, member services, provider relations, regulatory compliance, contract negotiations, quality, government relations, and medical management strongly preferred. Experience working in a matrixed environment strongly preferred. Understands how to collaborate, navigate and work within a structure with many direct and indirect reporting relationships; while still being the one accountable for the overall P&L of the plan. #SP1 Back Share Apply Now
Amerihealth Raleigh, NC, USA
Sep 15, 2019
Full time
Job Brief Interface with delegated provider groups and clinically integrated networks to complete required auditing and reporting related to provider delegation Your career starts now. We're looking for the next generation of health care leaders. At AmeriHealth Caritas, we're passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we'd like to hear from you. Headquartered in Philadelphia, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at . Responsibilities: As a member of the Population Health and Care Management team, the Care Management Oversight Coordinator will interface with delegated provider groups and clinically integrated networks to complete required auditing and reporting related to provider delegation, and ensure adherence with NCQA, and/or state, federal, and business requirements in conjunction with their agreement and the Requirements of the Medicaid Care Management program. Additional responsibilities include: Act as main point of contact for Delegates regarding processes associated with delegation. Conducts pre-delegation audits and ongoing auditing consistent with the Delegate's contract. Develop, implement and monitor delegate warning letters (dWL) and corrective action plans (dCAP) based on audit results. Works with Delegate and Practice Transformation team to assist delegate in meeting all requirements of delegation and/or a dWL/dCAP. Conducts regularly scheduled meetings with delegates regarding patient reconciliation and provides support to remove barriers to success. Participation in joint operating committee meetings that may require formal presentations Works with Care Management Oversight Support Specialist (CMOSS) to deliver reports and spreadsheets to delegates and appropriate committees. In conjunction with CMOSS reviews and analyzes data on delegate's performance against contract requirements and specifications for items such as HEDIS measures. Review delegation agreements and provide input to revise (as needed) any NCQA, Federal or State changes. Assist in managing the delegation policies and procedures. Coordinate with Care Management team and Transition of Care Specialist on any transition of care needs. Interface with functional departments to address any service related issues. Use critical thinking and problem solving skills to ensure successful delegation arrangements and quality data reporting. Education/Experience: Bachelor's Degree or equivalent work experience Registered Nurse. Displays good judgment in apprising management of situations that are incompatible with established policies for which there is little precedence. Strong ability to work independently Ability to represent the organization in a professional manner. Ability to prioritize and manage multiple tasks/priorities simultaneously. The ability to work in a fast paced environment. Demonstrate attention to detail. Strong ability to create, monitor and analyze provider data. Strong assessment and problem-solving skills. Excellent verbal and written communication skills, including the ability to present to small groups. Proficient in Access, Word, Excel, Power Point, etc. and company applications ie, CACTUS, Facets 3-5 years Care Management experience. #SP2 Back Share Apply Now
Amerihealth Raleigh, NC, USA
Sep 15, 2019
Full time
Job Brief Interface with delegated provider groups and clinically integrated networks to complete required auditing and reporting related to provider delegation Your career starts now. We're looking for the next generation of health care leaders. At AmeriHealth Caritas, we're passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we'd like to hear from you. Headquartered in Philadelphia, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at . Responsibilities: As a member of the Population Health and Care Management team, the Care Management Oversight Coordinator will interface with delegated provider groups and clinically integrated networks to complete required auditing and reporting related to provider delegation, and ensure adherence with NCQA, and/or state, federal, and business requirements in conjunction with their agreement and the Requirements of the Medicaid Care Management program. Additional responsibilities include: Act as main point of contact for Delegates regarding processes associated with delegation. Conducts pre-delegation audits and ongoing auditing consistent with the Delegate's contract. Develop, implement and monitor delegate warning letters (dWL) and corrective action plans (dCAP) based on audit results. Works with Delegate and Practice Transformation team to assist delegate in meeting all requirements of delegation and/or a dWL/dCAP. Conducts regularly scheduled meetings with delegates regarding patient reconciliation and provides support to remove barriers to success. Participation in joint operating committee meetings that may require formal presentations Works with Care Management Oversight Support Specialist (CMOSS) to deliver reports and spreadsheets to delegates and appropriate committees. In conjunction with CMOSS reviews and analyzes data on delegate's performance against contract requirements and specifications for items such as HEDIS measures. Review delegation agreements and provide input to revise (as needed) any NCQA, Federal or State changes. Assist in managing the delegation policies and procedures. Coordinate with Care Management team and Transition of Care Specialist on any transition of care needs. Interface with functional departments to address any service related issues. Use critical thinking and problem solving skills to ensure successful delegation arrangements and quality data reporting. Education/Experience: Bachelor's Degree or equivalent work experience Registered Nurse. Displays good judgment in apprising management of situations that are incompatible with established policies for which there is little precedence. Strong ability to work independently Ability to represent the organization in a professional manner. Ability to prioritize and manage multiple tasks/priorities simultaneously. The ability to work in a fast paced environment. Demonstrate attention to detail. Strong ability to create, monitor and analyze provider data. Strong assessment and problem-solving skills. Excellent verbal and written communication skills, including the ability to present to small groups. Proficient in Access, Word, Excel, Power Point, etc. and company applications ie, CACTUS, Facets 3-5 years Care Management experience. #SP2 Back Share Apply Now