Career


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)
app.apply_now

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.
app.apply_now
Pharmacy Technician Outreach Specialist
Job Description
 
Reports to: 
Salary: 
Status: Full-Time / Exempt
Location: Houston areas
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.

app.apply_now

Community Health Advocate

Job Description

 

Reports to:         Patient Services Director

Salary:                  $18 - $22 / hour

Status:                  Full-Time / Non-Exempt

Location:             Varies

 

Position Summary:

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

  1. Case Management and Care Coordination
  2. Home Based Support
  3. Health Promotion and Health Coaching
  4. 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.
app.apply_now

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.
app.apply_now