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. Assists Supervisor and Coordinator by acting as a liaison with providers, members, and internal decision-makers to meet contractual, regulatory, and accreditation requirements. Negotiates and resolves sensitive issues with internal and external parties. Gathers facts and research from various sources to present comprehensive explanations of members' or providers' positions to management and decision-makers. Triages cases to address initial inquiries effectively, aiming to serve members efficiently and minimize escalations.
Under management guidance, participates in cross-departmental committees and meetings to identify, clarify, research, and resolve inquiries and issues.
Identifies when policy or procedural changes are needed based on case resolutions, regulatory updates, or accreditation standards. Proposes policy or process changes to management based on analysis. Analyzes issues requiring multi-department efforts for resolution. Recommends actions to internal committees and management after discussion and approval. Assists in implementing decisions for change or resolution. Supports supervisors and managers in responding to investigations, audits, and inquiries related to regulations and accreditation. Helps internal customers with complex inquiries, guided by management.
Identifies member problems, educational needs, or trends, reporting these to managers and recommending solutions. Proactively reviews and communicates updates on regulations, standards, or business changes affecting member advocacy and appeals. Coordinates departmental changes as directed.
Performs quality assurance on case documentation and supports corporate activities as needed.
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. Assists Supervisor and Coordinator by acting as a liaison with providers, members, and internal decision-makers to meet contractual, regulatory, and accreditation requirements. Negotiates and resolves sensitive issues with internal and external parties. Gathers facts and research from various sources to present comprehensive explanations of members' or providers' positions to management and decision-makers. Triages cases to address initial inquiries effectively, aiming to serve members efficiently and minimize escalations.
Under management guidance, participates in cross-departmental committees and meetings to identify, clarify, research, and resolve inquiries and issues.
Identifies when policy or procedural changes are needed based on case resolutions, regulatory updates, or accreditation standards. Proposes policy or process changes to management based on analysis. Analyzes issues requiring multi-department efforts for resolution. Recommends actions to internal committees and management after discussion and approval. Assists in implementing decisions for change or resolution. Supports supervisors and managers in responding to investigations, audits, and inquiries related to regulations and accreditation. Helps internal customers with complex inquiries, guided by management.
Identifies member problems, educational needs, or trends, reporting these to managers and recommending solutions. Proactively reviews and communicates updates on regulations, standards, or business changes affecting member advocacy and appeals. Coordinates departmental changes as directed.
Performs quality assurance on case documentation and supports corporate activities as needed.
Performs other duties as assigned or directed.
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