HMSA
Job Responsibilities
Conducts critical analysis of highly complex and sensitive member and provider appeals, inquiries, and grievances, applying internal policies, contractual provisions, and regulatory requirements.
Secures information from internal and external resources to resolve issues. Functions as a liaison with providers, members, and internal decision makers, representing HMSA objectives, goals, and expectations for meeting contractual, regulatory, and accreditation requirements. Negotiates/resolves sensitive issues with internal and external parties. Negotiates fees on behalf of members for non-covered or nonparticipating provider services and solicits claims and medical information from providers to resolve member inquiries. Presents comprehensive explanations of member or provider positions and concerns to management and decision makers based on research and facts. Triages cases to resolve them promptly, aiming to minimize escalations to senior management and executives.
Participates in cross-departmental committees and internal meetings to identify, clarify, research, and resolve inquiries and issues.
Identifies when policy and procedural changes are needed based on case resolutions, regulatory changes, or accreditation standards. Proposes management changes based on analysis and findings. Analyzes issues requiring multi-department efforts and coordinates discussions to develop resolution processes. Presents recommendations to committees and management for decision-making related to cases. Supports the implementation of decisions for change or resolution. Assists with responses to internal investigations, audits, regulatory inquiries, and accreditation reviews. Helps internal customers with complex member and physician inquiries. Supports training efforts for supervisors and coordinators.
Identifies member problems, educational needs, or trends, reporting these to management and suggesting resolutions.
Proactively reviews and communicates changes in regulations, standards, or business processes affecting member advocacy and appeals, coordinating efforts across departments and assessing impacts.
Performs quality assurance on case documentation and supports corporate activities.
Performs other duties as assigned or directed.
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Conducts critical analysis of highly complex and sensitive member and provider appeals, inquiries, and grievances, applying internal policies, contractual provisions, and regulatory requirements.
Secures information from internal and external resources to resolve issues. Functions as a liaison with providers, members, and internal decision makers, representing HMSA objectives, goals, and expectations for meeting contractual, regulatory, and accreditation requirements. Negotiates/resolves sensitive issues with internal and external parties. Negotiates fees on behalf of members for non-covered or nonparticipating provider services and solicits claims and medical information from providers to resolve member inquiries. Presents comprehensive explanations of member or provider positions and concerns to management and decision makers based on research and facts. Triages cases to resolve them promptly, aiming to minimize escalations to senior management and executives.
Participates in cross-departmental committees and internal meetings to identify, clarify, research, and resolve inquiries and issues.
Identifies when policy and procedural changes are needed based on case resolutions, regulatory changes, or accreditation standards. Proposes management changes based on analysis and findings. Analyzes issues requiring multi-department efforts and coordinates discussions to develop resolution processes. Presents recommendations to committees and management for decision-making related to cases. Supports the implementation of decisions for change or resolution. Assists with responses to internal investigations, audits, regulatory inquiries, and accreditation reviews. Helps internal customers with complex member and physician inquiries. Supports training efforts for supervisors and coordinators.
Identifies member problems, educational needs, or trends, reporting these to management and suggesting resolutions.
Proactively reviews and communicates changes in regulations, standards, or business processes affecting member advocacy and appeals, coordinating efforts across departments and assessing impacts.
Performs quality assurance on case documentation and supports corporate activities.
Performs other duties as assigned or directed.
#J-18808-Ljbffr