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)
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.
You dream of a great career with a great company starts with the values you embrace and the dedication you bring to achieve your life's best work. Perseverance, confidence, motivated and determination are the necessary ingredients for success with IntegraNet Health.You dream of a great career with a great company starts with the values you embrace and the dedication you bring to achieve your life's best work. Perseverance, confidence, motivated and determination are the necessary ingredients for success with IntegraNet Health.
Position Summary:
Pharmacy Technician Outreach Specialist (PTOS). Will link patients with resources available within the IntegraNet Health continuum of care and/or the community at large. The PTOS for IntegraNet Health is a front-line public health worker who serves as a liaison and link between the company, the patient, pharmacy and health/social services. Will report directly to Dir. of Quality Compliance. This is Not a Retail Position.
Responsibilities:
Place outgoing phone calls to members, prescribers, and insurance companies to obtain clarification on prescription orders and refills.
Assist an assigned group of patients to achieve medication adherence goals by coordinating with pharmacy, patient and physicians for prescription fulfillment.
Coordinate with providers/member the possible transfer of prescriptions orders from other pharmacies when medication/s are not available.
Communicate with healthcare providers any upcoming prescription and follow-up with patient on new prescription orders and/or refills.
Collaborate with Provider Relations (PR) team, Community Health Workers (CHW), and Care Coordinator (CC) with escalated calls and non-standard customer service issues.
Coordinate and schedule in-person or virtual meetings with providers and/or staff to review members current Medication Adherence reports to identify barriers.
Research to help troubleshoot customer concerns and complaints.
Establish increased patient compliance through monitoring of prescriptions and refills by analyzing pharmacy data with Availity.
Documenting and tracking patient status after patients follow up calls.
Work closely with physician/pharmacist to ensure patients have comprehensive and coordinated care.
Achieve individual performance goals for productivity and quality.
Maintain confidentiality of patient and proprietary information at all times.
Other duties as assigned.
Required Qualifications:
Certified Pharmacy Technician (CPhT)
MUST be fluent in (reading and writing) English and another language (languages vary).
MUST have a clear driver’s license and reliable transportation, live in and have knowledge of the Houston-Metro area
1+ years of administrative support experience
6+ months experience in a medical setting
Basic knowledge of Microsoft Office products, including Word, Excel and Outlook.
Medical terminology knowledge base.
Ability to work independently, with some supervision and direction from superiors.
Demonstrate excellent organizational skills, customer service skills, verbal and written communication to patients, physicians, clinical staff, and managers.
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
Access to company gym and locker rooms in Houston offices.
The Pharmacy Technician Outreach Specialist (PTOS) for IntegraNet Health will assist an assigned group of patients in achieving medication adherence goals through coordination of patient, physician, and pharmacy for the fulfillment of meeting Part D quality measures. PTOS is also responsible for linking needed community resources and other value-added services within IntegraNet Health’s Patient Advocate program.
The Community Health Worker (CHW) for IntegraNet Health will assist an assigned group of patients to maintain a Primary Care Medical Home, as well as increasing their access to services within IntegraNet Health continuum of care and/or the community at large. The CHW will link patients with resources available to them within the community. The CHW for IntegraNet Health is a frontline public health worker who serves as a liaison and link between the company and health/social service
Roles and Objectives
Case Management and Care Coordination
Home Based Support
Health Promotion and Health Coaching
Resource and Benefits Navigation and Explanation
Case Management and Care Coordination:
Participating in care coordination and/or case management calls and outreach
Making referrals and providing follow-up with detailed explanations in accordance to patient’s benefits.
Facilitating transportation services and helping to address other barriers to access of care.
Documenting and tracking Patients status.
Be responsible for providing consistent communication to the Care Management Coordinator to evaluate patient/family status, ensuring that provided information, and reports clearly describe progress.
Providing necessary information to understand and prevent diseases and to help people manage health conditions (including chronic disease)
Work closely with medical provider to help ensure that patients have comprehensive and coordinated care.
Home Based Support:
Home visits to provide education, assessment, and social support
Responsible for establishing trusting relationships with patients and their families while providing general support and encouragement.
Providing ongoing follow-up, basic motivational interviewing and goal setting with patients/families.
Health Promotion and Health Coaching:
Providing ongoing follow-up, basic motivational interviewing and goal setting with patients/families.
Follow-up with patients via phone calls, home visits
Assist patients with completing applications and registration forms.
Help patients set personal goals, and attend appointments by providing appalment reminders.
Provide referrals for services to community agencies as appropriate.
Follow-up with patients should be continuous from initial identification through closure.
Resource and Benefits Navigation and Explanation:
Conduct eligibility determination, enrollment and follow-up.
Help triage patients to insurance advisors if interested in insurances changes
Qualifications:
MUST be CHW certified with a minimum of (2) years of experience.
MUST be fluent in English and another language (languages vary), reading and writing.
MUST have a clear license and reliable transportation.
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.