REPORTS TO: Medical Director, Director of Clinical Operations
LOCATION: Houston, TX
STATUS: Full time\exempt
GENERAL DESCRIPTION:
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.
QUALIFICATIONS, SKILLS, ABILITIES AND PROFESSIONAL COMPETENCIES:
Maintain a current nursing (RN or LVN) licensure in the State of Texas
Preferred knowledge in case management principles, utilization management procedures and practices
Demonstrates competent computer skills on Microsoft products and data base programs, including use of AaNeel Care
Ability to present ideas effectively, in both oral and/or written form
A driver’s license, reliable transportation
Be able to work in a stressful environment
Must have physical and mental stamina and be able to perform successfully under time-limited pressures
Have flexibility to adjust the schedule occasionally in order to accommodate other schedules and/or deadlines or projects
Must exhibit clear and tactful communications required via writing, reading, telephone calls, etc.
Must be able to travel, if needed.
Demonstrated computer literacy through successful completion on EMR
Must be physically able to operate a variety of automated office machines and equipment including, but not limited to, computer and printers, fax machines, copier, calculator and telephone.
Experience with Health Plans and Managed Care
Prior experience with Utilization Management
Previous training and demonstrated competence in negotiations, quality assurance and case management outcomes
Excellent relationship skills, including a high degree of psychological sophistication and non-aggressive assertiveness
Demonstrated ability to problem solve complex, multifaceted, emotionally charged situations
Ability to engage in abstract thought
Ability to successfully manage conflict, negotiating “win-win” solutions
Strong organizational, task prioritization, and delegation skills
Ability to construct grammatically correct reports using standard medical terminology
Patient advocacy focus
Empathy
ESSENTIAL JOB DUTIES:
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.
Cognitive and psychomotor capabilities in the diagnosis, treatment, and evaluation of patients and families.
Provides telephonic case management, referral of resources, education and other clinically based activities to plan member.
Provides medical management to plan members through communications with the members, the physician, other health care providers, the employer and the referral source.
Makes recommendations regarding health resources.
Collect clinical data and enters information into database for documentation purposes.
Monitors and evaluates the member’s response to health care needs.
Evaluates member’s treatment plan for appropriateness, medical necessity and cost effectiveness.
Implements care such as negotiating the delivery of durable medical equipment, assist with discharge planning, when applicable, and assist with arranging equipment through designated vendors.
Maintains an active caseload providing interventions as needed within area of expertise and limits of credentials.
Acquires and provides detailed information regarding an assigned member to establish the foundation for treatment plan.
Works with member using professional judgment and discretion to implement the team determined Team Plan.
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.
Use effective relationship management, coordination of services, resource management, education, patient advocacy, and related interventions to :
Promote improved quality of care and/or life
Promote cost effective medical outcomes
Prevent hospitalization when possible and appropriate
Provide for continuity of care
Assure appropriate levels of care are received by patients
Provide appropriate consultation and referral to Case Management Personnel.
Identify appropriate alternative and non-traditional resources and demonstrate creativity in managing each case to fully utilize all available resources.
Conduct patient satisfaction surveys.
Other duties as designed by Management.
DISCLAIMER
All requirements are subject to possible modification to reasonably accommodate qualified individuals.
A Job description in no way implies that the description includes every duty to be performed by the employee in the position. Employees will be required to follow any other job-related instructions and to perform any other job-related duties required by the Director of Utilization Management.
Job duties may vary depending on the level of experience of each employee.
The Assistant Practice Manager is a professional and knowledgeable individual who will be responsible for the overall operations, development and success of the medical practice. In this important role, the Assistant Practice Manager will be an information resource and ambassador to patients, the general public, Physicians and staff.
Responsibilities:
• Ensure office is opened and closed daily, as per established schedules.
• Interview, hire and train new staff in accordance with HR guidelines.
• Manage daily staffing to ensure optimal operation of the practice.
• Regularly review productivity and make staffing adjustments as needed.
• Monitor and approve time cards and track licensure requirements for staff.
• Conduct regular staff meetings and assist in the annual performance evaluations of practice staff.
• Review accounts receivable reports monthly.
Qualifications:
• Bachelor’s Degree in Healthcare Management or Business Administration preferred or 3+ years experience in medical office management.
• Working knowledge of medical terminology.
• Medical office billing experience preferred
• Proficiency with EMR systems and software applications and Microsoft Office Suite.
• Excellent written and oral communication skills.
• Fluent in Spanish 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.
• Schedules appointments and retrieving medical records from participating physician offices quarterly either by remote access or field (in physician office) collection. Reports to Chart Collection Manager
Job Duties:
• Contacts physician offices weekly to schedule available appointments to retrieve medical records.
• Must document all activity with doctor’s office or IntegraNet Departments concerning chart collection.
• Confirm collection method (EMR or paper) when scheduling for field collection. Bring appropriate collection materials such as laptop and scanner.
• Confirms appointments the day before a scheduled appointment. Resolve any issues so prospective appointments can be met or rescheduled effectively.
• Updates new appointments daily on the chart collection calendar for physicians and staff.
• Serves as point of contact for physicians and staff concerning chart retrieval for field collection.
• Travels 15% to 20% of time for collection each quarter, this includes Dallas and surrounding areas.
• Coordinates with other departments – Provider Relations, Coding and HEDIS Review as necessary to ensure proper and quality/usable data in the medical records is obtained.
• Must enter mileage each day for field collection.
• Maintains patient confidentiality by keeping patient records information confidential.
• Other job duties as assigned.
• Cross trains with others to ensure department activities can continue without interruption.
Skills and Qualifications:
• Reliable transportation and clear driving records required
• Must pass background check.
• Experienced in Microsoft Office required
• Heavy scheduling experience required
• Strong time management, productivity, organizational skills and attention to detail
• Professional and flexible, Productive, Deadline-Oriented, Reporting Skills required.
• Excellent communication skills
• Ability to work effectively as an individual and/or team, self-starter
• Bilingual - Spanish
• Experience reviewing medical records and imaging studies in multiple medical record platforms
• Critical thinking and problem-solving skills
• The employee frequently is required to stand; walk; use hands to finger, handle or feel; and reach with hands and arms; The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.
• This is a full-time position, and general hours are Monday through Friday, 8:00 a.m. to 5:00 p.m.
• This job operates in a professional office environment. This role routinely uses standard office equipment such as computers, phones, printers, and filing cabinets.
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.
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.
• 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.
• Follow set guidelines and time frames in order to scrutinize provider applications, resumes, licenses, etc. for consistency and accuracy.
• Work with providers and medical office staff to gather expired licenses and insurance information to maintain compliant files.
• Work closely with Provider Relations department.
• Maintain electronic files for all providers in network.
Knowledge and Skills:
• Excellent time management skills with an ability to work consistently within and meet monthly deadlines.
• Excellent written and verbal skills
• Ability to work independently with little supervision but able to work and communicate well with others when required.
• Able to follow concise directions and be well organized.
• Experience with Microsoft Outlook, Excel, Word, and Access and Adobe Acrobat
• Ability to work fax and copy machines, including scanning.
• Proofreading skills for auditing documents.
• Ability to maintain the confidentiality of all information within the department.
Education:
• High school diploma or equivalent.
• A minimum of 1 year of credentialing or equivalent work experience.
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.