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.
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. Must be Fluent in Chinese or Vietnamese.
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.
The Community Health Scheduler is responsible for maintaining accurate scheduling for Community Health Workers and assist the Patient Services Department in providing telephonic communication with patients and assisting them when needed.
Responsibilities:
Answer each incoming call with an energetic, friendly voice and direct calls to the appropriate person as needed.
Take caregiver inquiries over the phone, schedule interviews and conduct pre-screening
Create and maintain client records
Create and evaluate client and community health worker (CHW) schedules with an emphasis on creating rewarding and lasting relationships.
Take responsibility for making clients feel important to our company, including dealing with issues as they arise
Field new client inquiries over the phone with an emphasis on listening to the client, figuring out how we can serve them and then explaining how our care and customer service will solve their needs
Maintain regular attendance at the office and form positive communication skills with other office staff to execute responsibilities in a proper manner.
Willingness to carry on call phone for after hour and weekend inquiries/scheduling issues
Detail oriented
Qualifications:
Fluent in Spanish and English, reading and writing REQUIRED
Minimum 2 years high-volume call center experience REQUIRED
Minimum 1 year of scheduling experience REQUIRED
Community Health Worker (CHW) Accreditation preferred
Experience working in Managed Care preferred
Knowledge of the Texas Medicare and Medicaid population preferred
Licensed Insurance Agent for Health and Life preferred
Previous home health experience preferred
Knowledge of medical terminology preferred
Excellent computer skills, including working with Word, Excel, and other software programs
Excellent communication skills
Good energy, friendliness, a positive outlook, a passion for service to others, responsibility and initiative
Strong work ethic
High School Diploma or equivalent
Excellent time management skills
An ability to work in stressful or last-minute situations
A self-starter, someone who pitches in, wants to learn, grow and improve
Someone who wants and can earn upward mobility
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.
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.
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.
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.