Teams at Integra Partners

Leads external utilization management audits, regulatory inquiries, and compliance oversight across Medicare, Medicaid, Commercial, and Dual Eligible populations. Reviews UM records and audit findings, analyzes large datasets in Excel, validates regulatory timelines and performance metrics, drafts evidence-based responses, develops corrective action plans, and supports audit readiness. Partners with operational teams, clients, regulators, and accreditation organizations to resolve discrepancies, identify compliance risks, and improve processes.

Supports clinical utilization management teams with administrative processing of prior authorizations and appeals. Responsibilities include entering authorization requests, verifying eligibility and documentation, contacting providers, issuing notifications, completing verbal notifications, initiating appeals, documenting cases, and meeting regulatory deadlines. Requires knowledge of ICD-10, HCPCS codes, medical terminology, managed care processes, and strong organizational and communication skills.

Manages the corporate compliance program for payer services, including audits, fraud, waste and abuse investigations, compliance training, licensing, policy updates, risk assessments, and regulatory research. Partners with health plans, DME providers, internal teams, legal, and data security staff to address compliance and security concerns. Oversees a compliance analyst and supports HIPAA, CMS, Medicare, Medicaid, credentialing, and healthcare regulatory obligations.