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Reports to: Chief Nursing Officer

Salary: TBD based upon Experience

Status: Full-Time / Permanent / Exempt/ Part- Time Remote

Location: Houston, TX

Position Summary:

The Utilization Review Nurse works independently to plan, implement, and/or coordinate quality patient care and cost-effective utilization of healthcare services. Utilization Review Nurse coordinates medical and/or pharmacy prior authorization request, perform preadmission, concurrent and retrospective review of inpatient admissions and outpatient services, identifies cases for case management.

Responsibilities:

  • Applies nationally accepted criteria that include general rules and time definitions to determine appropriate levels of care and to illuminate resource utilization practices with provider organizations.
  • Skill and proficiency in applying highly technical and critical thinking principles, concepts, and techniques that are central to the Nursing profession.
  • Makes recommendations regarding health resources.
  • Collect clinical data and enters information into database for documentation purposes.
  • Evaluates member’s treatment plan for appropriateness, medical necessity and cost effectiveness.
  • Maintains an active caseload providing interventions as needed within area of expertise and limits of credentials.
  • Maintains a high level of ethical conduct regarding confidentiality, dual-relationships, and professional stature.
  • Participate in continuing education activities, remaining knowledgeable in areas of expertise
  • Attend meetings as appropriate and meet regularly with supervisor to exchange pertinent information and receive supervision
  • Timely completion of documentation, follow-up, etc. within specified deadlines.
  • Perform verification and pre-certification authorizations using approved guidelines, screening criteria and protocols and refers authorizations to the Medical Director that require additional expertise.
  • Perform concurrent review to validate the medical necessity for admissions, determine the appropriate level of care and the necessity for continued inpatient stay.
  • Monitor retrospective review requests based on established review guidelines.
  • Assist with discharge planning for members who have been hospitalized.
  • Provide appropriate consultation and referral to Case Management Personnel.
  • Other duties as designed by Management.
  • Partial Remote

Qualifications:

  • MUST maintain a current RN or LVN license in the State of Texas
  • MUST HAVE prior experience with Utilization Management
  • MUST have prior experience with a physician network or health plan
  • MUST have Milliman Guidelines (MCG) experience Intequal, Standard National Care Guidelines or equivalent
  • MUST have flexibility to adjust the schedule occasionally in order to accommodate other schedules and/or deadlines or projects
  • Qualifying Internet capabilities
  • Preferred knowledge in case management principles, utilization management procedures and practices

Company Benefits:

In a full-time permanent position, you will be able to participate in our company benefit program which includes:

  • Group benefits include medical, dental, vision, company paid $25k life with the option to add more voluntary life insurance coverage for employee and their family, STD, company paid LTD, 401k, and a variety of supplemental coverages such as hospital, cancer, legal, etc. available to the employee and their family.
  • Employer funded HSA and HRA programs.
  • Paid Time Off ranging from 5-28 days depending on length of service.
  • Profit Sharing Bonus Program
  • 100% Employer Paid Pension Plan after 5 years
  • Access to company gym and locker rooms in Houston offices.

Job Type: Full-time

Experience:

  • Utilization Management: 1 year (Required)
  • physician network or health plan: 1 year (Required)
  • Milliman Guidelines (MCG) or Intequal: 1 year (Required)

Location:

  • Houston, TX (Required)

License:

  • RN or LVN license in Texas (Required)

Language:

  • Spanish (Preferred)

Work authorization:

  • United States (Required)
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Credentialing Assistant

Reports to Director of Credentialing

Salary:  $10.00 – 18.00 per hour

Status: Full-Time / Exempt

Location: Houston

 

Position Summary

The credentialing assistant prepares and submits credentialing and recredentialing applications. They also follow up on the status of applications for physicians and keep a detailed log of all pending and completed work.

We are a fast-paced office, currently maintaining the credentialing and re-credentialing applications for 1200+ physicians, mid-levels, and ancillary facilities. The ideal candidate will have a minimum of 1 years’ experience with physician, mid-level, and/or ancillary credentialing preferably in a healthcare environment. Must have outstanding communication and interpersonal abilities, excellent organizational skills, strong attention to detail and the ability to work in a team environment. Must be proficient with Microsoft Office Products (Excel, Word and Microsoft Outlook). 

 

Job Duties:

1. Responsible for gathering and verifying provider information either through CAQH, fax, or mail. Compiling required documents, research erroneous information, and verifying all provider information through various online resources.

2. Follow set guidelines and time frames in order to scrutinize provider applications, resumes, licenses, etc. for consistency and accuracy.

3. Work with providers and medical office staff to gather expired licenses and insurance information to maintain compliant files.

4. Work closely with Provider Relations department.

5. Maintain electronic files for all providers in network.

Qualifications:

1.  A minimum of 1 year of credentialing or equivalent work experience.

2. Excellent time management skills with an ability to work consistently within and meet monthly deadlines.

3. Excellent written and verbal skills

4. Ability to work independently with little supervision but able to work and communicate well with others when required.

5. Able to follow concise directions and be well organized.

6. Experience with Microsoft Outlook, Excel, Word, and Access and Adobe Acrobat

7. Ability to work fax and copy machines, including scanning.

8. Proofreading skills for auditing documents.

9. Ability to maintain the confidentiality of all information within the department

 

Education:

1. High school diploma or equivalent.

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Reports to:         Cequoia Davis

Salary:                  $40k - $55k

Status:                  Full-Time / Exempt

Location:             Houston, TX

 

Position Summary:

The Provider Relations Representative is responsible for establishing and maintaining strong business relationships with provider types, ensuring each of their territory compositions include an appropriate distribution of provider specialties and provide in depth, high level educational instruction and support to physicians and their staff. This is an account management position and will be the main point of contact for the respective providers. Will routinely visit physician’s offices for issues concerning the achievement of provider satisfaction, medical cost targets, network growth and/or efficiency targets, education of benefits, policy and procedure for managed care plans, assistance with claims payments, financial compensation and marketing. Generally, work is self-directed and not prescribed; works with less structure, but more complex issues. Travel requirements – local and extensive.
Responsibilities:

  • Develop the provider network of assigned territory (family practice, cardiology, etc.) yielding a geographically competitive, broad access, stable network that achieves objectives for unit cost performance and trend management, and produce a comprehensive product for business partners.
  • Intermediary between Health Plans and Providers concerning provider participation, claim issues, additions, terminations
  • Daily visits to physician offices
  • Provide Orientations and ongoing education to physicians and staff on Health Plans policies, procedures and resource information
  • Develop a strong relationship with office staff and physician to promote their growth in the network.
  • Review bonus matrix with physicians for each quarterly distribution.
  • Proven ability to synthesize and translate competitive intelligence into decision-making process
  • Analyze Data to identify cost driver and share/educate physicians on improvement options
  • Provide advice/guidance/recommendations and insight to leadership regarding assigned network territory
  • Negotiates provider contracts as applicable
  • Participates in quarterly Provider Forums
  • Serves as a resource to others.
  • Assist staff with proper claims payment when necessary.
  • Assist Health Plans and Physicians with HEDIS compliance and data collection
  • Works with other departments on a daily basis
  • Assist with special projects

Qualifications:

  • 2+ years of experience in Provider Relations with a Physician Network or Health Plan (4+ for Senior) REQUIRED
  • Knowledge of Medicare Managed Care REQUIRED
  • Knowledge of CMS Medicare Advantage Risk Adjustment, Star rating program, and HEDIS preferred
  • Knowledge of Direct Medicare record collection and understanding of ICD9/ICD10, CPT 4 billing requirements preferred
  • Reliable transportation REQUIRED
  • MUST live in the recruiting area
  • Knowledge of claims processing and guidelines a plus
  • Strong interpersonal skills, establishing rapport and working well with others
  • Excellent verbal and written communication skills; ability to speak clearly and concisely, conveying complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others (a critical thinker with presentation skills)
  • Analytical/data drive decision-making skills
  • Working knowledge of provider business operations
  • Proven ability to synthesize and translate competitive intelligence into decision-making process
  • Familiar with Microsoft applications including Outlook, Word and Excel. Experience with Access a plus.
  • Must be self-motivated and work independently; able to translate concepts into practice

Company Benefits:

In a full-time permanent position, you will be able to participate in our company benefit program which includes:

  • Group benefits include medical, dental, vision, company paid $25k life with the option to add more voluntary life insurance coverage for employee and their family, STD, company paid LTD, 401k, and a variety of supplemental coverages such as hospital, cancer, legal, etc. available to the employee and their family.
  • Employer funded HSA program.
  • Paid Time Off ranging from 5-28 days depending on length of service.
  • Profit Sharing Bonus Program
  • 100% Employer Paid Pension Plan after 5 years
  • 24/7 access to company gym and locker rooms in Houston offices.

 

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Provider Relations Representative (Vietnamese)

Job Description

 

Reports to:         Cequoia Davis

Salary:                  $40k - $55k

Status:                  Full-Time / Exempt

Location:             Houston, TX

 

Position Summary:

The Provider Relations Representative is responsible for establishing and maintaining strong business relationships with provider types, ensuring each of their territory compositions include an appropriate distribution of provider specialties and provide in depth, high level educational instruction and support to physicians and their staff. This is an account management position and will be the main point of contact for the respective providers. Will routinely visit physician’s offices for issues concerning the achievement of provider satisfaction, medical cost targets, network growth and/or efficiency targets, education of benefits, policy and procedure for managed care plans, assistance with claims payments, financial compensation and marketing. Generally, work is self-directed and not prescribed; works with less structure, but more complex issues. Travel requirements – local and extensive.
Responsibilities:

  • Develop the provider network of assigned territory (family practice, cardiology, etc.) yielding a geographically competitive, broad access, stable network that achieves objectives for unit cost performance and trend management, and produce a comprehensive product for business partners.
  • Intermediary between Health Plans and Providers concerning provider participation, claim issues, additions, terminations
  • Daily visits to physician offices
  • Provide Orientations and ongoing education to physicians and staff on Health Plans policies, procedures and resource information
  • Develop a strong relationship with office staff and physician to promote their growth in the network.
  • Review bonus matrix with physicians for each quarterly distribution.
  • Proven ability to synthesize and translate competitive intelligence into decision-making process
  • Analyze Data to identify cost driver and share/educate physicians on improvement options
  • Provide advice/guidance/recommendations and insight to leadership regarding assigned network territory
  • Negotiates provider contracts as applicable
  • Participates in quarterly Provider Forums
  • Serves as a resource to others.
  • Assist staff with proper claims payment when necessary.
  • Assist Health Plans and Physicians with HEDIS compliance and data collection
  • Works with other departments on a daily basis
  • Assist with special projects

Qualifications:

  • 2+ years of experience in Provider Relations with a Physician Network or Health Plan (4+ for Senior) REQUIRED
  • Knowledge of Medicare Managed Care REQUIRED
  • Knowledge of CMS Medicare Advantage Risk Adjustment, Star rating program, and HEDIS preferred
  • Knowledge of Direct Medicare record collection and understanding of ICD9/ICD10, CPT 4 billing requirements preferred
  • Reliable transportation REQUIRED
  • MUST live in the recruiting area
  • Fluent in Vietnamese required
  • Knowledge of claims processing and guidelines a plus
  • Strong interpersonal skills, establishing rapport and working well with others
  • Excellent verbal and written communication skills; ability to speak clearly and concisely, conveying complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others (a critical thinker with presentation skills)
  • Analytical/data drive decision-making skills
  • Working knowledge of provider business operations
  • Proven ability to synthesize and translate competitive intelligence into decision-making process
  • Familiar with Microsoft applications including Outlook, Word and Excel. Experience with Access a plus.
  • Must be self-motivated and work independently; able to translate concepts into practice

Company Benefits:

In a full-time permanent position, you will be able to participate in our company benefit program which includes:

  • Group benefits include medical, dental, vision, company paid $25k life with the option to add more voluntary life insurance coverage for employee and their family, STD, company paid LTD, 401k, and a variety of supplemental coverages such as hospital, cancer, legal, etc. available to the employee and their family.
  • Employer funded HSA program.
  • Paid Time Off ranging from 5-28 days depending on length of service.
  • Profit Sharing Bonus Program
  • 100% Employer Paid Pension Plan after 5 years
  • 24/7 access to company gym and locker rooms in Houston offices.
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Provider Relations Representative

Job Description

 

Reports to:         Provider Relations Manager

Salary:                  $40k - $55k ($55k - $70k for Senior)

Status:                  Full-Time / Exempt

Location:             Dallas, TX

 

Position Summary:

The Provider Relations Representative is responsible for establishing and maintaining strong business relationships with provider types, ensuring each of their territory compositions include an appropriate distribution of provider specialties and provide in depth, high level educational instruction and support to physicians and their staff. This is an account management position and will be the main point of contact for the respective providers. Will routinely visit physician’s offices for issues concerning the achievement of provider satisfaction, medical cost targets, network growth and/or efficiency targets, education of benefits, policy and procedure for managed care plans, assistance with claims payments, financial compensation and marketing. Generally, work is self-directed and not prescribed; works with less structure, but more complex issues. Travel requirements – local and extensive.

 

Responsibilities:

  • Develop the provider network of assigned territory (family practice, cardiology, etc.) yielding a geographically competitive, broad access, stable network that achieves objectives for unit cost performance and trend management, and produce a comprehensive product for business partners.
  • Intermediary between Health Plans and Providers concerning provider participation, claim issues, additions, terminations
  • Daily visits to physician offices
  • Provide Orientations and ongoing education to physicians and staff on Health Plans policies, procedures and resource information
  • Develop a strong relationship with office staff and physician to promote their growth in the network.
  • Review bonus matrix with physicians for each quarterly distribution.
  • Proven ability to synthesize and translate competitive intelligence into decision-making process
  • Analyze Data to identify cost driver and share/educate physicians on improvement options
  • Provide advice/guidance/recommendations and insight to leadership regarding assigned network territory
  • Negotiates provider contracts as applicable
  • Participates in quarterly Provider Forums
  • Serves as a resource to others.
  • Assist staff with proper claims payment when necessary.
  • Assist Health Plans and Physicians with HEDIS compliance and data collection
  • Works with other departments on a daily basis
  • Assist with special projects

 

Qualifications:

  • 2+ years of experience in Provider Relations with a Physician Network or Health Plan (4+ for Senior) REQUIRED
  • Knowledge of Medicare Managed Care REQUIRED
  • Knowledge of CMS Medicare Advantage Risk Adjustment, Star rating program, and HEDIS preferred
  • Knowledge of Direct Medicare record collection and understanding of ICD9/ICD10, CPT 4 billing requirements preferred
  • Reliable transportation REQUIRED
  • MUST live in the recruiting area
  • Fluent in Spanish a plus
  • Knowledge of claims processing and guidelines a plus
  • Strong interpersonal skills, establishing rapport and working well with others
  • Excellent verbal and written communication skills; ability to speak clearly and concisely, conveying complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others (a critical thinker with presentation skills)
  • Analytical/data drive decision-making skills
  • Working knowledge of provider business operations
  • Proven ability to synthesize and translate competitive intelligence into decision-making process
  • Familiar with Microsoft applications including Outlook, Word and Excel. Experience with Access a plus.
  • Must be self-motivated and work independently; able to translate concepts into practice

 

Company Benefits:

 

In a full-time permanent position, you will be able to participate in our company benefit program which includes:

  • Group benefits include medical, dental, vision, company paid $25k life with the option to add more voluntary life insurance coverage for employee and their family, STD, company paid LTD, 401k, and a variety of supplemental coverages such as hospital, cancer, legal, etc. available to the employee and their family.
  • Employer funded HSA program.
  • Paid Time Off ranging from 5-28 days depending on length of service.
  • Profit Sharing Bonus Program
  • 100% Employer Paid Pension Plan after 5 years
  • 24/7 access to company gym and locker rooms in Houston offices.
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QUALIFICATIONS:

  • Medical billing and coding certification preferred.
  • Recent experience in CPT and ICD-10 coding; familiarity with medical terminology
  • Minimum 2+ years of experience with family practice and internal medicine billing and coding preferred.
  • Bilingual in Spanish and English preferred.
  • Accurate medical billing data entry skills.
  • Strong analytical skills.
  • Ability to work with deadlines while remaining calm, flexible and organized.
  • Proficiency with electronic medical records (EMRs)
  • Computer experience (MSWord, EXCEL, E-Mail, and practice management system(s).
  • Ability to prioritize and manage multiple tasks effectively and meet tight deadlines.
  • Experience dealing with insurance companies and managed care plans.
  • Ability to work independently and collaboratively within a team environment.
  • Demonstrate a self-motivated, persistent, and dedicated personality to overcome setbacks and ensure ultimate success.
  • Professional, businesslike image.

PRIMARY DUTIES AND RESPONSIBLITIES:

  • Ensure all claims are submitted with a goal of zero errors.
  • Review insurance claims for accuracy and completeness and obtain any missing information.
  • Ability to convert dosages to billable units as well familiar with NDC for drug administrations.
  • Completion of insurance claims and submit to payers per time filing guidelines.
  • Check eligibility and benefit verification prior to claim submission
  • Review claims for HEDIS as well the usage of proper modifiers.
  • Prepare, review, and transmit claims using billing software, including electronic and paper claim processing.
  • Monthly unbilled reports to be reconciled with the client.
  • Comply with HIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies and other applicable corporate and departmental policies.
  • Maintain complete confidentiality of company business.
  • Travel to other offices as needed.
  • Attend staff meetings as required.
  • Maintain a high level of ethical conduct regarding confidentiality, dual-relationships, and professional stature.
  • Participate in continuing education activities, remaining knowledgeable in areas of expertise
  • Timely completion of documentation, follow-up, etc. within specified deadlines.
  • All other tasks and duties as directed by management.
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HEDIS/GPRO Quality Nurse

Job Description

 

Reports to:         Designated Market Lead

Salary:                  $65K - $85K

Status:                  Full-Time/Exempt

Location:             Houston, TX

 

Position Summary:

 

This position serves as an integral member of the Quality and Provider Relations Team and reports to the designated Market Lead of Employer (IPA).  This role is a key contributor to the training of providers and their staff on HEDIS and GPRO measures and is accountable for all providers achieving a minimum of 4-STAR for HEDIS and 95% quality for GPRO as well as other duties as assigned by the Market Lead. This is a field position requiring travel to doctors’ offices regularly.

 

 

Responsibilities:

  • Advises and educates providers and their staff in the appropriate documentation of HEDIS and GPRO measures, medical record documentation guidelines and HEDIS ICD-9/10 CPT coding in accordance with NCQA requirements.
  • Collects, summarizes and trends provider performance data to identify and strategize opportunities for provider improvement.
  • Collaborates with Provider Relations to improve provider performance in areas of Quality, Risk Adjustment and Operations (claims and encounters).
  • Delivers provider specific metrics and coaches Providers on gap closing opportunities.
  • Identifies specific practice needs where IntegraNet Health can provide support.
  • Leads and/or supports collaborative business partnerships, promote client understanding and insight to advise and make recommendations.
  • Partners with physicians/physician staff to find ways to explore new ways to encourage member clinical participation in wellness and education.
  • Provides resources and educational opportunities to provider and staff.
  • Captures concerns and issues in action plans as agreed upon by provider and in formats approved by IPA.
  • Documents action plans and details of visits and outcomes and reports critical incidents and information regarding quality of care issues.
  • Communicates with external data sources as authorized to gather data necessary to measure identified outcomes.
  • Provides IPA approved communication such as newsletter articles, member education, outreach interventions and provider education.
  • Supports Provider office-based quality improvement and program studies as needed, requesting records from providers, maintaining databases, and researching to identify members' provider encounter history.
  • Ensures that documentation produced and/or processed complies with state regulations and/or accrediting body requirements.
  • Ensures assigned contract/regulatory report content is accurate and that submission adheres to deadline.
  • Participates in and represents IPA at community, health department, collaborative and other organizational meetings focusing on quality improvement, member education, and disparity programs, as assigned.
  •  Works with office-based staff to ensure accuracy in medical records for data collection, data entry and reporting. Enters documentation of findings in identified databases.
  • Performs other duties as assigned.

Qualifications:

  • Licensed Vocational Nurse (LVN) or Licensed Registered Nurse (RN)
  • 5+ years working with HEDIS and GPRO with an IPA or health plan in a senior role.
  • Knowledge of computer systems and applications.  Skill in planning, organizing, prioritizing, delegating and supervising. 
  • Skill in exercising initiative, judgment, problem-solving, decision-making. 
  • Skill in identifying and resolving problems. 
  • Ability to anticipate and react calmly in emergency situations. 
  • Skill in developing and maintaining effective relationships with medical and administrative staff, patients and the public. 
  • Skill in developing comprehensive reports. 
  • Ability to analyze and interpret complex data. 
  • Skill in developing and maintaining office-based quality improvement.   
  • Excellent and effective written and verbal communication skills. 

 

Company Benefits:

 

In a full-time permanent position, you will be able to participate in our company benefit program which includes:

  • Group benefits include medical, dental, vision, company paid $25k life with the option to add more voluntary life insurance coverage for employee and their family, STD, company paid LTD, 401k, and a variety of supplemental coverages such as hospital, cancer, legal, etc. available to the employee and their family.
  • Employer funded HSA program.
  • Paid Time Off ranging from 5-28 days depending on length of service.
  • Profit Sharing Bonus Program
  • 100% Employer Paid Pension Plan after 5 years
  • Employer Sponsored Wellness Program with access to company gym and locker rooms in Houston offices, if applicable.
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Ancillary/Hospital Contractor

Job Description

 

Reports to:         COO

Salary:                  $65k - $75k

Status:                  Full-Time / Exempt

Location:             Houston, TX

 

Position Summary:

 

The Ancillary/Hospital Contractor will be responsible for the recruitment of Ancillary and Hospital Partners into the Houston Metro market. This role will be responsible for significantly growing market share and managing the contracting process to ensure compliance within CMS guidelines. The Ancillary/Hospital Contractor will initiate partnerships and work with the CEO & COO in initial implementation of partnership programs to support operational and strategic goals.

 

Responsibilities:

 

  • Serves as primary point of contact between IntegraNet Health and physician, specialists, and ancillary partners interested in joining the network.
  • Participates in negotiations of financial arrangements for partnerships.
  • Manages the contracting process at the market level.
  • Conducts market research to identify potential candidates to join the network.
  • Tracks recruitment and assists in business development activities.
  • Develops and creates marketing materials to support market-level initiatives and campaigns.
  • Plans events to engage current and future network participants.
  • Coordinates the development of professional, effective relationships within area hospitals, physicians, and ancillary providers.
  • Maintains requisition skills to build the network through relationship-building and communication.
  • Travels throughout regional area to attend meetings to recruit and conduct presentations.
  • All other duties as assigned by Supervisor.

Qualifications:

 

  • Bachelor’s Degree in health administration preferred or equivalent experience.
  • Considerable knowledge of Managed Care and the Medi-Cal line of business.
  • 3+ years experience negotiating professional and ancillary provider contracts or equivalent experience to support negotiations.
  • Thorough knowledge of provider contracting models and network development.
  • Experience in provider relations and client services preferred.
  • Strong ability to express ideas clearly in both written and oral communications.
  • Ability to develop, organize, analyze and implement processes and procedures.
  • Proficiency with Microsoft applications, Word, Excel and Access.
  • Effective interpersonal skills.
  • Financial and analytical skills a plus.

 

Company Benefits:

 

In a full-time permanent position, you will be able to participate in our company benefit program which includes:

  • Group benefits include medical, dental, vision, company paid $25k life with the option to add more voluntary life insurance coverage for employee and their family, STD, company paid LTD, 401k, and a variety of supplemental coverages such as hospital, cancer, legal, etc. available to the employee and their family.
  • Employer funded HSA program.
  • Paid Time Off ranging from 5-28 days depending on length of service.
  • Profit Sharing Bonus Program
  • 100% Employer Paid Pension Plan after 5 years
  • Employer Sponsored Wellness Program with access to company gym and locker rooms in Houston offices.
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Manager Healthcare Claims Operations???????

Job Description

Job Title:            Manger Health Care Claims Operations

Reports to:         Mark Gilliam

Status:                Full-Time / Exempt

Location:            Houston, TX

 

Position Summary:

Our claims manager is responsible for overseeing claims adjudication activity within the appropriate CMS and/or State guidelines. Point of Contact for health plan delegation audits. Identify payment/denial trends. Reporting performance standards. Responsible for day-to-day department functions including staff placement, training, supervision and productivity. Monitor claims data for possible fraudulent billing from providers, support claim system coding provider contract language and assist with general provider billing questions.

 

Responsibilities:

  • Managing a team of adjusters and examiners
  • Ensuring legal compliance of the claims process
  • Building and motivating the team to hit productivity goals
  • Adjusting protocols based on contracts
  • Attending educational sessions in the event of new laws or changing business directives
  • Settling difficult or complex claims
  • Develops and implements work plan with actionable components and measurable outcomes
  • Proactively monitors key performance indicators and displays that information through dashboards and metrics and makes real time adjustments.
  • Manage provider and member appeal policies and workflows to include compliance with internal service level agreements and state, federal and health plan regulatory requirements.

Qualifications:

  • At least 5 years of experience in Health Care, managed care
  • At least 2 year of experience in a supervisory/ managerial/
  • Excellent analytical and problem-solving skills
  • Ability to organize, document, and control both digital and physical data
  • Bachelor’s degree in related field or experience
  • Extensive knowledge of reimbursement methodologies specific to Facility and Professional Claims
  • Extensive knowledge of Claims Software
  • Knowledge of DRG Payment, Grouper/Pricers
  • Delegation Oversight Experience (Health Plan, CMS)
  • Excellent communication skills
  • Knowledge of enrollment, eligibility, and utilization review processes
  • Knowledge of industry standards specific to CMS & TDI
  • Provider contract interpretation and system development

Company Benefits:

In a full-time permanent position, you will be able to participate in our company benefit program which includes:

  • Group benefits include medical, dental, vision, company paid $25k life with the option to add more voluntary life insurance coverage for employee and their family, STD, company paid LTD, 401k, and a variety of supplemental coverages such as hospital, cancer, legal, etc. available to the employee and their family.
  • Employer funded HSA program.
  • Paid Time Off ranging from 5-28 days depending on length of service.
  • Profit Sharing Bonus Program
  • 100% Employer Paid Pension Plan after 5 years
  • Employer Sponsored Wellness Program with access to company gym and locker rooms in Houston offices.
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Job Title:             Customer Care Representative I

Reports to:         COO

Status:                  Full-Time / Exempt

Location:             Houston, TX

 

Position Summary:

As a customer care representative, you will act as a trusted advisor and educator on health care related inquires. You will guide our patients to a better healthcare experience, working every day to make healthcare easy by the service you provide.

 

Responsibilities:

  • Proactively resolve member and/or provider concerns.
  • Assisting Providers and Patients find a doctor via telephone calls, online chats or e-mails.
  • Partner with internal departments to create a seamless experience to resolve potential issues.
  • Must be able to work 8-hour shifts, between 8am-5pm.
  • Answers questions and resolves issues based on phone calls/letters from members, providers, and plan sponsors
  • Document and track contact with members, providers, and plan sponsors
  • Handles incoming requests for appeals and pre-authorizations.
  • Other job duties as assigned
  • Triages resulting rework to appropriate staff.
  • Educates providers on our self-service options

 

Qualifications:

  • High school diploma
  • 1 year of experience in customer service (including excellent communication both verbal and written and problem-solving skill
  • Any combination of education and experience, which would provide and equivalent background)
  • A passion for serving others with the ability to be empathetic and the desire to help resolve members questions at the first point of contact
  • Must have a strong work ethic and sense of responsibility for your teammates and our members
  • Ability to multi-task to accomplish workload efficiently
  • Understanding of medical terminology
  • Ability to maintain accuracy and production standards.
  • Technical skills
  • Attention to detail and accuracy
  • Analytical skills
  • Experience in a production environment
  • High school or GED Equivalent

 

Company Benefits:

In a full-time permanent position, you will be able to participate in our company benefit program which includes:

  • Group benefits include medical, dental, vision, company paid $25k life with the option to add more voluntary life insurance coverage for employee and their family, STD, company paid LTD, 401k, and a variety of supplemental coverages such as hospital, cancer, legal, etc. available to the employee and their family.
  • Employer funded HSA program.
  • Paid Time Off ranging from 5-28 days depending on length of service.
  • Profit Sharing Bonus Program
  • 100% Employer Paid Pension Plan after 5 years
  • Employer Sponsored Wellness Program with access to company gym and locker rooms in Houston offices.
app.apply_now