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Job Description

 

TITLE: Utilization Review Nurse

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. 

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Job Description

 

Reports to:         Designated Market Lead

Status:                  Full-Time/Exempt

Location:             Dallas, TX

 

Position Summary:

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.

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We are looking for highly analytical candidates who are as skilled in healthcare administration as they are in business management. Healthcare Data Analysts are quantitative specialists who understand the business needs of an IPA and how to use data to achieve those needs. Their duties include organizing and managing large and varied data sets, analyzing health care data to optimize business operations and communicating their findings using data visualization and detailed reports.

 

The best healthcare data analysts are diligent problem solvers who use data in creative ways to reach business goals.

 

Reports to:         Mark Gilliam

Salary:                  $40,000-$50,000

Status:                  Full-Time / Exempt

Location:             Houston, TX

 

Position Summary:

 

 

Responsibilities:

 

  • Compiling and organizing healthcare data.
  • Analyzing data to assist in delivering optimal healthcare management and decision making.
  • Using healthcare data to achieve administrative needs and goals.
  • Understanding data storage and data sharing methods.
  • Investigating data to find patterns and trends.
  • Understanding healthcare business operations.
  • Utilizing different data sources for analyses.
  • Converting data into usable information that is easy to understand.
  • Developing reports and presentations.
  • Communicating analytic insights to management.

Qualifications:

 

  • Bachelor’s degree in Mathematics, Statistics, Healthcare Administration or related field.
  • Master’s degree advantageous.
  • Proficiency with database programming languages such as SQL.
  • Experience with data visualization tools.
  • Knowledge of data management applications.
  • Proficiency managing electronic medical records.
  • Analytical mindset with good problem-solving skills.
  • Excellent written and verbal communication skills.
  • Good interpersonal 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.

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Job Description

Department:

Quality

Location:

Houston, Tx

Job Title

Clinical Pharmacist

Reports to:

 

 

Type of position: CHECK ALL THAT APPLY

 

-Full time

-40 hr/week

 

GENERAL DESCRIPTION/PURPOSE

This position is primarily responsible for performing and supervising pharmacist activities related to all Pharmacy Quality Initiatives (i.e. RxQI, MTMP, CPAS, Medication Adherence (with a focus on Medicare Advantage), Hospital Discharge Program, Fraud Waste and Abuse monitoring for IntegraNet Health. This position will oversee program staff as well as monitor and report ongoing progress of pharmacy quality initiatives. This position will also perform operational maintenance and/or implementation of new clinical services as well as any additional duties deemed necessary for the Pharmacy Services Department.  The incumbent serves as a Clinical Pharmacist (CP) as part of an interdisciplinary healthcare team and providing optimal clinical and pharmaceutical care activities in accordance with the department’s mission, vision and goals.

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 RESPONSIBILITIES

  • Develop clinical pharmacy programs according to policies and regulations
  • Provide patient-centered education on chronic disease states including medications used for prevention and treatment
  • Participate in clinical department meetings and forums to improve clinical programs, enhance processes, and share clinical information
  • Utilize health plan formulary information to guide appropriate medication recommendations
  • Complete referrals from care management, transitions of care team, and clinic provider teams for high risk patients including review of polypharmacy, high risk medications, high cost medications, medication adherence, and uncontrolled chronic disease states
  • Assist in medication cost management including therapeutic substitution recommendations, high cost medication reviews, and medication usage evaluations
  • Support in improvement of clinic NCQA, HEDIS, and CMS STAR quality measures
  • Assist in the development and presentation of educational materials for patients and providers
  • Provide patient-centered education on chronic disease states including medications used for prevention and treatment
  • Collaborate with healthcare professionals to ensure optimal patient care
  • Collaborate with prescribers, interdisciplinary care teams, patients and/or caregivers to identify and develop patient-specific disease state therapy goals
  • Oversee program staff as well as monitor and report ongoing progress of pharmacy quality initiatives
  • Perform all other duties as assigned to meet departmental objectives
  • Communicate professionally and discuss/document clinical recommendations/interventions to prescribers and interdisciplinary care teams

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.

REQUIRED QUALIFICATIONS AND SKILLS

 

  • Excellent communication (verbal and written) and interpersonal skills
  • Ability to work in a team environment and support common goals
  • Ability to prioritize multiple tasks, anticipate, and solve problems
  • Comfortable working in a rapidly changing and highly matrixed organization
  • Attention to detail and ability to concentrate without distraction in a fast-paced environment
  • Ability to be self-directed and possess excellent organizational skills
  • Proven experience as clinical pharmacist
  • Residency training and current license are required
  • Excellent understanding of pharmaceutical therapy and direct patient care
  • Solid knowledge of drug administration and health & safety guidelines
  • Working knowledge of computers
  • Team player with outstanding communication skills (verbal and written)
  • Aptitude in problem-solving and decision-making
  • Strong professional ethics
  • Degree in Pharmacy/Pharmacology
  • 3+ years of health plan or IPA experience in managing Medication Adherence Programs

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.

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 matching, and a variety of supplemental coverages such as hospital, cancer, legal, etc. available to the employee and their family.
  • Employee 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