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 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.
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
Knowledge in Healthcare Authorizations, Benefits, and Claims
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.
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.
Bilingual (Spanish, Mandarin, or Cantonese)
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.
Position Summary: Our fast-paced Independent Physician Association company is seeking a Public Relations Specialist to manage all aspects of our public-facing brand. We are interested in penetrating new markets and increasing brand visibility. The successful candidate will be responsible for unifying our brand across all print and digital channels, establishing, and managing a social media presence across multiple platforms and creating an editorial calendar for content marketing, also managing, and coordinating quarterly newsletters. If you love helping small companies grow into their potential, we look forward to discussing this position with you.
Responsibilities:
Create effective public events.
Arrange publicity opportunities such as speaking engagements, appearances, and interviews.
Draft talking points and help prepare for press visits, conferences, and interviews.
Oversee social media activity and content to ensure that the client is always viewed in a positive light.
Manage day to day relations with media and other platforms.
Cultivate relationships with journalists in order to place stories with them; good publicists understand the inner workings of the media so they can recognize the stories that certain journalists want to write about
Discern which stories are obvious and do not require much in the way of promotion.
Pitch new content.
Helping ensure brand consistency across marking materials.
Helping members and physicians understand what IntegraNet offers.
Planning and directing Public Relation programs
Responding to information requests from clients and members of the media
Writing or editing speeches
Responding to information requests from clients and members of the media
Publish and manage monthly/quarterly newsletters.
Promote and manage monthly Health Fairs and other events.
Manage website and website content.
Required Qualifications:
Bachelor’s degree in journalism or public relations
Proven experience working as a publicist in the healthcare industry.
Strong knowledge of current affairs in healthcare.
Impeccable interpersonal and social skills
Efficient multitasking and time management abilities
Excellent verbal and written communication skills
Exceptional debating and public speaking abilities
Professional appearance and demeanor
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.
Position Summary:
This position is responsible for all accounting, financial reporting, and sales and property tax reporting to external agencies.
Responsibilities:
Sales invoicing
Account receivable and collections
Purchase orders and accounts payable.
Monthly state sales tax
General Ledger and Bank account reconciliations
Notes payable
Payroll processing
Financial statement preparation
Special projects for projections and proformas as needed.
Financial Management
Work within approved budget; uses cost-saving measures; contributes to profits and revenue.
Receive all appropriate approvals (e.g., purchase orders, expense reports) for incurred expenses
Customer Service
Interact with all visitors and fellow employees in a mature, responsible, courteous manner to ensure a positive and professional environment. Responds promptly to customer and coworker needs, and continually strives to improve service.
Maintain sensitive information in a confidential and professional manner.
PHYSICAL REQUIREMENTS
While performing the duties of this Job, the employee is regularly required to talk or hear. The employee is frequently required to sit and use hands and fingers, handle, type, or feel. The employee is occasionally required to stand; walk; reach with hands and arms and stoop, kneel, crouch, or crawl. The employee must occasionally lift and/or move up to 25 pounds. Specific vision abilities required by this job include close vision and distance vision.
Machines/Equipment Used
Computers, copy machines, telephone, fax machine and other equipment as necessary
Environmental Conditions
Indoor climate-controlled environment; occasional exposure to outdoor climate. Moderate to quiet noise level.
Required Qualifications:
BA in Accounting
CPA Eligible
required skills
Knowledge of US Generally Accepted Accounting Principles
Proficient in various accounting software programs as well as spreadsheet and word programs.
Appeals/Reconsiderations Specialist is responsible for analyzing and resolving written claims, reconsiderations and/or appeals from providers. Ensure payments and/or denials are made in accordance with company practices and procedures. Determine if denials should be overturned or upheld and document cases. Prepare response letters for providers and members. Preparing departmental reports as needed.
COMPANY GENERAL POLICY AND PROCEDURE
Attendance: Is punctual and present. Will request time off in accordance with policy. Will document time worked and reasons for tardiness/absence or leaving early according to office policy.
The requirements listed below are representative of the knowledge, skill, and/or ability required. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The competence of the employee in performing his or her job duties will be demonstrated, maintained, and improved on an ongoing basis.
The statements contained in this position description reflect the general duties considered necessary to describe the principal functions of the job as identified, and shall not be considered a detailed description of all the work requirements that may be inherent in the position.
job responsibilites
Functions as a liaison between the Plan and providers by responding to their needs and inquiries and educating providers and their office staff.
Coordinates corrective actions related to multifaceted provider issues and complex claims analyses.
May create various claims projects related to provider inquiries resolutions.
Must have the ability to effectively communicate provider issues to internal and external stakeholders
Coordinates education and provider data corrections because of encounter file submission errors.
Participates in cross-functional team meetings for trend identification for training initiatives.
Performs other duties and projects as assigned.
Apply policy and provider contract provisions to determine if claim is payable, if additional information is needed, or if claim should be denied. Claims, reconsiderations, and appeals processing may be related to physician and hospital services, coordination of benefits (COB), high dollar, special pricing, refunds and/or adjustments on resubmitted claims.
Research and determine status of medical related claims
Review charges access the computer system and use payment or denial codes within established department guidelines and standards
Clarify health insurance coverage for coordination of benefits to process claims
Maintain records, files, and documentation as appropriate
Meet department production and quality standards
Perform or assist with other duties and projects as needed.
required qualifications and skills
High School Graduate / Some Advance Learning in related field, required
3-5 years of claims processing experience or comparable experience
Previous Provider interaction in a Managed care setting preferred, specifically Medicare
Working knowledge of electronic claims submission and online authorizations.
Understanding Plan policies and procedures related to provider contracting, provider billing and payment, physician and hospital incentive programs, and other key state regulatory requirements relating to providers.
Intermediate understanding of Microsoft Excel
Ability to work independently, with little supervision
Working knowledge of ICD-10, CPT, HCPCs, revenue codes, and medical terminology preferred. Experience with Medicare claims preferred.
Proficiency in Microsoft Word, Excel, Outlook, and PowerPoint.
Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.
Ability to read and interpret documents. Ability to write routine reports and correspondence.
Quality: Demonstrate accuracy and thoroughness, look for ways to improve and promote quality. Apply feedback to performance and monitor own work to ensure quality.
Quantity: Meet productivity standards and complete work in a timely manner. Strive to increase productivity.
PHYSICAL REQUIREMENTS
While performing the duties of this Job, the employee is regularly required to talk or hear. The employee is frequently required to sit and use hands and fingers, handle, type, or feel. The employee is occasionally required to stand; walk; reach with hands and arms and stoop, kneel, crouch, or crawl. The employee must occasionally lift and/or move up to 25 pounds. Specific vision abilities required by this job include close vision and distance vision.
Machines/Equipment Used
Computers, copy machines, telephone, fax machine and other equipment as necessary
Environmental Conditions
Indoor climate-controlled environment; occasional exposure to outdoor climate. Moderate to quiet noise level.
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.