Position Summary:
The HP3- Social Worker (TS) provides immediate assessment and assistance for patients at the clinic. This key individual must make quick determinations to manage a crisis and properly channel a course of treatment. The HP3- Social Worker (TS) participates of the patients’ family matters and identifies social limitations that might affect treatment. The HP3- Social Worker (TS) coordinates with communitarian agencies for other services that could be needed for patient treatment.
Essential Functions:
1. Evaluates patients through interviews and gathers clinic, social and health information necessary for effective analysis. Advises patients about rights, responsibilities, treatment consents and proper actions. Full time employees must evaluate a minimum of 14 patients per day; Part time employees must evaluate a minimum of 8 patients per day.
2. Analyses, plans, develop and administer patient treatments focusing on patient’s wellbeing and participation. Offers individual, family and group therapy, considering actions that effectively benefit the patient and provides support.
3. Revises and monitors treatment plan and prioritizes courses of action. Considers factors that could affect treatment and consults with other professionals in order to assure the patients wellbeing.
4. Refer and coordinates with communitarian agencies for services that benefit and are convenient for treatment. Offers workshops and educational talks to beneficiaries APS Healthcare patients in open waiting room.
5. Collaborates with hospitalization when necessary; revises patients under Intensive Management Program (Clinic Level) for high utilization.
6. Promotes and participates in case discussions to multi and interdisciplinary teams, as well as interagency level.
7. Responsible for monthly calendar for case discussion with providers, agencies or others; Completes necessary reports for agencies according to social needs.
8. Documents attendance and interventions in the patient file and keeps them in a safe, confidential area.
9. Complies with all guidelines established by the Centers for Medicare and Medicaid (CMS) and guidelines set forth by other regulatory agencies, where applicable; Complies with regulatory patient waiting time of no more than 1 hour, as established by law.
10. And all other duties assigned by the manager and/or supervisor.
Education:
• Master’s degree in Clinic Social Work.
• Must have current, unrestricted license to practice in the Puerto Rico territory and Professional College Membership.
Experience:
• Minimum 2+ years of experience in the mental health field of related.
Knowledge:
• Knowledge of the mental health law; Law 408.
• Must demonstrate extensive knowledge of the laws that protect services for children, elderly people, persons with special needs (Special Education), persons with disabilities, mental health patients, family relations and legal and remedies for compulsory admission to rehabilitation’s programs.
• Knowledge of the DSMV, diagnosis and pharmacology.
• Personal computer experience should include working with Microsoft Word, Excel, Power Point and Outlook at the intermediate level at a minimum.
Position Summary:
The HP3- Social Worker (TS) provides immediate assessment and assistance for patients at the clinic. This key individual must make quick determinations to manage a crisis and properly channel a course of treatment. The HP3- Social Worker (TS) participates of the patients’ family matters and identifies social limitations that might affect treatment. The HP3- Social Worker (TS) coordinates with communitarian agencies for other services that could be needed for patient treatment.
Essential Functions:
1. Evaluates patients through interviews and gathers clinic, social and health information necessary for effective analysis. Advises patients about rights, responsibilities, treatment consents and proper actions. Full time employees must evaluate a minimum of 14 patients per day; Part time employees must evaluate a minimum of 8 patients per day.
2. Analyses, plans, develop and administer patient treatments focusing on patient’s wellbeing and participation. Offers individual, family and group therapy, considering actions that effectively benefit the patient and provides support.
3. Revises and monitors treatment plan and prioritizes courses of action. Considers factors that could affect treatment and consults with other professionals in order to assure the patients wellbeing.
4. Refer and coordinates with communitarian agencies for services that benefit and are convenient for treatment. Offers workshops and educational talks to beneficiaries APS Healthcare patients in open waiting room.
5. Collaborates with hospitalization when necessary; revises patients under Intensive Management Program (Clinic Level) for high utilization.
6. Promotes and participates in case discussions to multi and interdisciplinary teams, as well as interagency level.
7. Responsible for monthly calendar for case discussion with providers, agencies or others; Completes necessary reports for agencies according to social needs.
8. Documents attendance and interventions in the patient file and keeps them in a safe, confidential area.
9. Complies with all guidelines established by the Centers for Medicare and Medicaid (CMS) and guidelines set forth by other regulatory agencies, where applicable; Complies with regulatory patient waiting time of no more than 1 hour, as established by law.
10. And all other duties assigned by the manager and/or supervisor.
Education:
• Master’s degree in Clinic Social Work.
• Must have current, unrestricted license to practice in the Puerto Rico territory and Professional College Membership.
Experience:
• Minimum 2+ years of experience in the mental health field of related.
Knowledge:
• Knowledge of the mental health law; Law 408.
• Must demonstrate extensive knowledge of the laws that protect services for children, elderly people, persons with special needs (Special Education), persons with disabilities, mental health patients, family relations and legal and remedies for compulsory admission to rehabilitation’s programs.
• Knowledge of the DSMV, diagnosis and pharmacology.
• Personal computer experience should include working with Microsoft Word, Excel, Power Point and Outlook at the intermediate level at a minimum.
Position Summary:
The Client Services Supervisor supervises daily clinical call center staff and operations. These key individual coaches and develops team members in accordance with departmental goals and objectives to ensure quality of service, rapid response, suitable documentation, and compliance with performance metrics.
Essential Functions:
Education:
Minimum 3 years of experience in a managed care position or related.Supervision experience preferred.Knowledge:
Knowledge in customer service and emergency call handling and telephonic necessity identification. Proficient in data entry skills.Personal computer experience should include working with Microsoft Word, Excel, Power Point and Outlook at the intermediate level at a minimum.Position Summary:
The Client Services Supervisor supervises daily clinical call center staff and operations. These key individual coaches and develops team members in accordance with departmental goals and objectives to ensure quality of service, rapid response, suitable documentation, and compliance with performance metrics.
Essential Functions:
Education:
Minimum 3 years of experience in a managed care position or related.Supervision experience preferred.Knowledge:
Knowledge in customer service and emergency call handling and telephonic necessity identification. Proficient in data entry skills.Personal computer experience should include working with Microsoft Word, Excel, Power Point and Outlook at the intermediate level at a minimum.Resumen del Puesto:
El Profesional de la Salud (HP3) realiza revisiones de utilización y/o atención telefónica al cliente; resolución de problemas, seguimiento y otros servicios relacionados para pacientes y miembros. Este individuo clave se enfoca en la participación, educación y empoderamiento de los miembros, estableciendo recomendaciones que ayudan a manejar condiciones de salud crónicas y fomentan estilos de vida más saludables. Debe estar disponible mientras el personal no clínico realiza la evaluación inicial.
Funciones Esenciales:
Proporciona asesoría y consulta en salud, ya sea telefónica o presencial, para participantes y miembros, cumpliendo con las políticas y procedimientos de la compañía.Verifica y documenta la elegibilidad de los miembros para los servicios.Investiga, revisa y mantiene datos relacionados con el tratamiento, la atención y/o servicios relacionados, identificando barreras que puedan afectar o interferir con la efectividad o adherencia al tratamiento.Realiza triaje y evaluaciones urgentes de riesgo clínico, consultas de experto clínico, resolución de problemas a corto plazo, coordinación de servicios clínicos de emergencia o urgentes, referencias y/o seguimiento para miembros que buscan servicios, según sea necesario.Participa en determinaciones organizacionales para casos de hospitalización completa o parcial, incluyendo pre-certificación y revisiones concurrentes, discutiendo preocupaciones de necesidad clínica/médica con el Asesor Médico interno, según sea necesario.Colabora con otros profesionales para obtener mejores resultados de tratamiento y atención general.Se comunica e interactúa en encuentros “en vivo” con proveedores para facilitar y coordinar las actividades del proceso de Gestión de Utilización.Verifica y ajusta los informes de Censo de todas las instalaciones de hospitalización completa/parcial, realiza revisiones concurrentes y retrospectivas cumpliendo con las políticas y procedimientos de la compañía.Colabora con las instalaciones en la planificación de alta. Completa el resumen de alta utilizando la información clínica provista por las instalaciones al cierre del caso. Genera números de autorización para fines de pago, para todos los servicios de hospitalización completa o parcial determinados en el proceso de revisión.Aplica el proceso de autorización APS (estándares Milliman, políticas, procedimientos y acuerdos contractuales) a la información presentada. Autoriza servicios de acuerdo con las guías médicas y de salud.Coordina con la fuente de referencia si no hay suficiente información disponible para completar el proceso de autorización. Informa a la fuente de referencia y solicita la información específica necesaria para completar el proceso. Documenta la solicitud y sigue el proceso para pedir información adicional.Proporciona determinaciones organizacionales verbales/email/fax de manera oportuna al proveedor solicitante y/o miembros según la política. Envía la documentación/información clínica apropiada al personal administrativo para archivo, envío de notificaciones y requisitos de documentación.Reconoce oportunidades para referencias a Manejo de Casos de Salud Conductual y refiere según corresponda. Identifica preocupaciones de calidad durante el proceso de revisión y las remite al Departamento de Calidad para investigación adicional.Cumple con todas las guías establecidas por los Centros de Medicare y Medicaid (CMS), NCQA, URAC y otras agencias regulatorias, así como HIPAA cuando corresponda; obtiene la educación profesional y continua necesaria para la licencia y cualquier certificación aplicable.Además, realiza todas las demás tareas asignadas por el gerente y/o supervisor.Educación:
Maestría en un campo de Salud Conductual o bachillerato en Enfermería.Licencia(s) clínica(s) vigente(s) y sin restricciones para ejercer en el territorio de Puerto Rico.Experiencia:
Mínimo 2 años de experiencia en un campo Clínico, Conductual o de Cuidado Administrado (preferido).Conocimientos:
Experiencia en computadoras personales que incluya manejo de Microsoft Word, Excel, PowerPoint y Outlook a nivel intermedio como mínimo.Sólido conocimiento en principios de conducta, enfermedades crónicas y manejo de enfermedades.Fuertes habilidades de evaluación telefónica y servicio al cliente.Conocimiento de recursos comunitarios.Conocimiento en evaluación clínica e intervención en crisis.Experiencia en computadoras personales que incluya manejo de Microsoft Word, Excel, PowerPoint y Outlook a nivel intermedio como mínimo. Read LessPosition Summary:
The Health Professional 3/ EAP performs telephonic assessments; provides short-term problem resolution, referral and follow up for managers, employees and family members covered by APS’ Employee Assistance Programs as well as OPTIMIND Programs. This key individual achieves outstanding customer and member service, and addresses providers’ needs as established by the organization. Must be available while non-clinical staff performs initial screening.
Essential Functions:
Performs risk assessments; short-term problem resolution, referrals, follow up and authorization for members seeking services.Assists callers in crisis and develops immediate action plans for callers presenting any risk. Demonstrates thorough understanding of the mental health and substance abuse treatment system to be able to guide clients, employers or family members to the appropriate level of care available. Assesses workplace and management issues while providing suggestions and developing action plans. Prepares, coordinates and facilitates trainings regarding clinical topics, as well as onsite program orientations and workshops.Complies with all guidelines established by the Centers for Medicare and Medicaid (CMS), NCQA, URAC and guidelines set forth by other regulatory agencies & HIPAA where applicable; obtains necessary professional and continuing education required for licensure and any applicable certifications. In addition, all other duties assigned by the manager and/or supervisor.Education:
Master’s Degree in a Behavioral Health field or Bachelor’s Degree in Nursing. Current, unrestricted clinical license(s) to practice in Puerto Rico territory.Experience:
Minimum 2 years of experience in a Clinical, Behavioral or Managed Care field preferred.Knowledge:
Personal computer experience should include working with Microsoft Word, Excel, Power Point and Outlook at the intermediate level at a minimum.Strong knowledge in behavior principles, chronic illnesses and disease management. Strong telephonic assessment and customer service skills.Knowledge in community based resources.Knowledge in clinical assessment and crisis intervention.Personal computer experience should include working with Microsoft Word, Excel, Power Point and Outlook at the intermediate level at a minimum. Read LessPosition Summary:
The Health Professional 3/ EAP performs telephonic assessments; provides short-term problem resolution, referral and follow up for managers, employees and family members covered by APS’ Employee Assistance Programs as well as OPTIMIND Programs. This key individual achieves outstanding customer and member service, and addresses providers’ needs as established by the organization. Must be available while non-clinical staff performs initial screening.
Essential Functions:
Performs risk assessments; short-term problem resolution, referrals, follow up and authorization for members seeking services.Assists callers in crisis and develops immediate action plans for callers presenting any risk. Demonstrates thorough understanding of the mental health and substance abuse treatment system to be able to guide clients, employers or family members to the appropriate level of care available. Assesses workplace and management issues while providing suggestions and developing action plans. Prepares, coordinates and facilitates trainings regarding clinical topics, as well as onsite program orientations and workshops.Complies with all guidelines established by the Centers for Medicare and Medicaid (CMS), NCQA, URAC and guidelines set forth by other regulatory agencies & HIPAA where applicable; obtains necessary professional and continuing education required for licensure and any applicable certifications. In addition, all other duties assigned by the manager and/or supervisor.Education:
Master’s Degree in a Behavioral Health field or Bachelor’s Degree in Nursing. Current, unrestricted clinical license(s) to practice in Puerto Rico territory.Experience:
Minimum 2 years of experience in a Clinical, Behavioral or Managed Care field preferred.Knowledge:
Personal computer experience should include working with Microsoft Word, Excel, Power Point and Outlook at the intermediate level at a minimum.Strong knowledge in behavior principles, chronic illnesses and disease management. Strong telephonic assessment and customer service skills.Knowledge in community based resources.Knowledge in clinical assessment and crisis intervention.Personal computer experience should include working with Microsoft Word, Excel, Power Point and Outlook at the intermediate level at a minimum. Read LessPosition Summary:
The Health Professional 3 conducts utilization review, and/or telephonic customer care; problem resolution, follow up and further related services for patients and members. This key individual focuses on member engagement, education, and empowerment, establishing recommendations that manage chronic health conditions and are conductive to healthier lifestyles. Must be available while non-clinical staff performs initial screening.
Essential Functions:
Provides telephonic and/or in person health coaching and consultation for participants and members, while meeting company policies and procedures. Verifies and documents member eligibility for services. Investigates, reviews, and maintains data related to treatment, care and/or related services and identifies barriers that could affect or interfere with treatment effectiveness or adherence. Performs triage and urgent clinical risk assessment, clinical expert consultation, short-term problem resolution, clinical emergency or urgent services coordination, referral and/or follow up for members seeking services, as needed. Participates in organization determinations for either Inpatient or Partial Hospitalization cases including pre-certification and concurrent reviews, while discussing clinical/medical necessity concerns within house Physician Advisor, as needed. Collaborates with other professionals to obtain better treatment results and overall care. Communicates and interacts via “live” encounters with providers to facilitate and coordinate the activities of the Utilization Management process. Verifies and adjusts Census reports for all Inpatient/Partial Hospitalization facilities, conducts concurrent and retrospective reviews while meeting company policies and procedures. Collaborates with facilities in the Discharge planning. Completes Discharge summary using the clinical information provided by facilities at case closure. Generates authorization numbers for payment purposes, for all Inpatient or Partial services as determined in the review process. Applies APS authorization process (Milliman standards, policies, procedures, and contractual agreements) to submitted information. Authorizes services in accordance with medical and health guidelines. Coordinates with the referral source if there is not sufficient information available to complete the authorization process. Advises the referral source and requests specific information necessary to complete the process. Documents the request and follows process for requesting additional information. Provides timely verbal/email/fax organization determinations to the requesting provider and/or members as per policy. Submits appropriate documentation/clinical information to clerical support for record keeping, mailing notifications and documentation requirements. Recognizes opportunities for referrals to Behavioral Health Case Management and refers accordingly. Identifies quality concerns through the review process and refers them to Quality Department for further investigation.Complies with all guidelines established by the Centers for Medicare and Medicaid (CMS), NCQA, URAC and guidelines set forth by other regulatory agencies & HIPAA where applicable; obtains necessary professional and continuing education required for licensure and any applicable certifications. In addition, all other duties assigned by the manager and/or supervisor.Education:
Master’s Degree in a Behavioral Health field or bachelor’s degree in Nursing. Current, unrestricted clinical license(s) to practice in Puerto Rico territory.Experience:
Minimum 2 years of experience in a Clinical, Behavioral or Managed Care field preferred.Knowledge:
Personal computer experience should include working with Microsoft Word, Excel, Power Point and Outlook at the intermediate level at a minimum.Strong knowledge in behavior principles, chronic illnesses, and disease management. Strong telephonic assessment and customer service skills.Knowledge in community-based resources.Knowledge in clinical assessment and crisis intervention.Personal computer experience should include working with Microsoft Word, Excel, Power Point and Outlook at the intermediate level at a minimum. Read LessPosition Summary:
The Health Professional 3 conducts utilization review, and/or telephonic customer care; problem resolution, follow up and further related services for patients and members. This key individual focuses on member engagement, education, and empowerment, establishing recommendations that manage chronic health conditions and are conductive to healthier lifestyles. Must be available while non-clinical staff performs initial screening.
Essential Functions:
Provides telephonic and/or in person health coaching and consultation for participants and members, while meeting company policies and procedures. Verifies and documents member eligibility for services. Investigates, reviews, and maintains data related to treatment, care and/or related services and identifies barriers that could affect or interfere with treatment effectiveness or adherence. Performs triage and urgent clinical risk assessment, clinical expert consultation, short-term problem resolution, clinical emergency or urgent services coordination, referral and/or follow up for members seeking services, as needed. Participates in organization determinations for either Inpatient or Partial Hospitalization cases including pre-certification and concurrent reviews, while discussing clinical/medical necessity concerns within house Physician Advisor, as needed. Collaborates with other professionals to obtain better treatment results and overall care. Communicates and interacts via “live” encounters with providers to facilitate and coordinate the activities of the Utilization Management process. Verifies and adjusts Census reports for all Inpatient/Partial Hospitalization facilities, conducts concurrent and retrospective reviews while meeting company policies and procedures. Collaborates with facilities in the Discharge planning. Completes Discharge summary using the clinical information provided by facilities at case closure. Generates authorization numbers for payment purposes, for all Inpatient or Partial services as determined in the review process. Applies APS authorization process (Milliman standards, policies, procedures, and contractual agreements) to submitted information. Authorizes services in accordance with medical and health guidelines. Coordinates with the referral source if there is not sufficient information available to complete the authorization process. Advises the referral source and requests specific information necessary to complete the process. Documents the request and follows process for requesting additional information. Provides timely verbal/email/fax organization determinations to the requesting provider and/or members as per policy. Submits appropriate documentation/clinical information to clerical support for record keeping, mailing notifications and documentation requirements. Recognizes opportunities for referrals to Behavioral Health Case Management and refers accordingly. Identifies quality concerns through the review process and refers them to Quality Department for further investigation.Complies with all guidelines established by the Centers for Medicare and Medicaid (CMS), NCQA, URAC and guidelines set forth by other regulatory agencies & HIPAA where applicable; obtains necessary professional and continuing education required for licensure and any applicable certifications. In addition, all other duties assigned by the manager and/or supervisor.Education:
Master’s Degree in a Behavioral Health field or bachelor’s degree in Nursing. Current, unrestricted clinical license(s) to practice in Puerto Rico territory.Experience:
Minimum 2 years of experience in a Clinical, Behavioral or Managed Care field preferred.Knowledge:
Personal computer experience should include working with Microsoft Word, Excel, Power Point and Outlook at the intermediate level at a minimum.Strong knowledge in behavior principles, chronic illnesses, and disease management. Strong telephonic assessment and customer service skills.Knowledge in community-based resources.Knowledge in clinical assessment and crisis intervention.Personal computer experience should include working with Microsoft Word, Excel, Power Point and Outlook at the intermediate level at a minimum. Read Less
Position Summary:
The Billing Coordinator will follow up on unpaid claims utilizing monthly aging reports, filing appeals when appropriate to obtain maximum reimbursement. Process and monitor incoming payments and secure revenue by verifying and posting receipts in compliance with financial policies and procedures.
Essential Functions:
Collect, post, and manage patient account payments.Submit claims, investigate rejected claims to see why denial was issued.Submit appeals and reconsiderations to insurance.Review delinquent accounts and call for collection purposes. Escalate problem accounts to Manager to obtain payment.Process payments from insurance companies.Performs various collection actions including contacting patients by phone, correcting and resubmitting claims to third party payers.Handle information about patient treatment, diagnosis, and related procedures to ensure proper coding.Reports possible instances of fraud and abuse, if found.Complies with all guidelines established by the Centers for Medicare and Medicaid (CMS) and guidelines set forth by other regulatory agencies, where applicable.Provide training in billing practices.In addition, all other duties assigned by the manager and/or supervisor.Education:
Certified High School Diploma or equivalent.Experience:
Minimum 3 years experience in medical billing with billing or medical coding certification. Knowledge of insurance guidelines. Experience in filing claim appeals with insurance companies to ensure maximum entitled reimbursementKnowledge:
Personal computer experience should include working with Microsoft Word, Excel, Power Point and Outlook at the intermediate level at a minimum. Experience in CPT and ICD-10 coding; familiarity with medical terminology. Know several different coding systems, including Level 1 HCPCS and Level 2 HCPCS. Read Less