Are you searching for a fulfilling role that can make a significant difference in healthcare? At Innovista, we're devoted to driving transformative change in this essential sector. Our independent physician partners achieve exceptional results in every aspect of value-based care, contributing to enhanced patient care and improved practice outcomes. Innovista Health is a full-service management services organization with a commitment to revolutionizing practice, offering solutions like multi-payer program administration, quality, utilization, and care coordination services, as well as performance improvement insights and reporting.  

Innovista Health Solutions, based in Illinois, is an organization with a far-reaching influence, operating in both Illinois and Texas. At Innovista, we trust in the power of innovative programs and dedicated people to propel us forward in today's ever-changing healthcare market.  

 This fully remote position is a fantastic opportunity for you to become a part of our Houston, TX team, leading the charge toward a superior, more efficient healthcare system.  

JOB SUMMARY:

Provide internal support to the Medical Management Department in the areas of Outpatient Case Management ensuring all services referred are reviewed according to plan requirements and approved criteria.

DUTIES AND RESPONSIBILITIES:

• Effectively communicates to management and internal departments timely.
• Receives and responds to all incoming calls from PCP, specialists, and other providers regarding inpatients, surgeries, and outpatient services including DME, Home Health Care, and other services requiring a pre-authorization.
• Coordinates DME with contracted HMO vendors for outpatient services.
• Coordinate with Inpatient Case Manager on discharge planning of members (DME, Home Health, and Skilled Nursing).
• Coordinates and reviews retro surgical procedures with Manager.
• Understands Health Plan policies and procedures regarding pre-authorization, benefits by health plan, and preferred facilities within each plan.
• Enters data and coordinates elective admissions with a surgical component.
• Maintains compliance with all health plan guidelines on the reporting of cases/surgeries.
• Works with clinical staff to assess benefit levels for non-medical denial determination to ensure the denial process includes letter and log maintenance.
• Identifies potential stop-loss candidates to be monitored and reports to a senior-level manager.
• Applies Innovista guidelines and additional approved criteria as detailed in the client UM Plan for the length of stay/admission criteria to approve initial and continued inpatient services.
• Other duties as assigned.

• High School Diploma or equivalent experience required. 
• At least 2-3 years of relevant professional experience, including managed care and quality.
• Being knowledgeable in using InterQual and/or MCG (Milliman) guidelines is a plus.                      
• Able to effectively communicate technical concepts and basic business concepts with team members and internal customers.   

BENEFITS:

At Innovista, we prioritize attracting talented individuals who embody our core values of integrity, determination, and teamwork. We understand the significance of balancing personal life with work commitments and hence offer a comprehensive benefits package to support our team. Our offerings include: 

• A robust health benefits package with subsidized medical insurance, including Flexible Spending Account (FSA), Health Savings Account (HSA), and Health Reimbursement Account (HRA) options, complemented by dental and vision coverage. 
• Assurance of financial security with company-paid benefits such as short and long-term disability, employee life, and Accidental Death and Dismemberment (AD&D) policies. 
• A yearly discretionary bonus, enhancing your financial prospects. 
• A generous paid time off policy that appreciates and rewards your loyalty and tenure with the company. 
• Paid company holidays and parental leave, ensuring time for relaxation and family. 
• Access to our Employee Assistance Program, supporting you in times of need. 
• A 401(k) scheme with a company match, supporting your future financial stability. 
• The opportunity for flexible work arrangements including remote or hybrid work, and potentially adjustable work hours. 
• Opportunities for continuous education, fostering personal growth and development. 
• A "Dress for Your Day" policy, promoting comfort and individuality. 
• Access to discounted gym memberships via medical coverage, promoting wellness and health. 
• Clear career advancement and growth pathways, recognizing your hard work and ambition. 
• Rewarding employee referral bonuses for expanding our team with like-minded individuals. 
• An open-door policy that encourages direct communication with our CEO and upper management, fostering transparency and inclusivity in our work culture.