- Support day-to-day business operations and functions. This includes processing claims, member/provider servicing (both in-person and telephonically), identifying trends in operational efficiencies, researching inquiry escalations, and responding to secure messages, written correspondence, and refunds.
- Support cross functional teams (including but not limited to HMSA staff and external partners and providers) to collect, communicate and distribute information and conduct quantitative/qualitative analysis to identify areas of opportunity and make recommendations for department/corporate action to support FEP Plan Incentive Program (PIP) metrics.
- Develop methods to improve daily customer service and claims processing operations and practice standards. This includes, but is not limited to, analyzing business problems, enhancements to add functionality and/or redesign of systems to improve efficiencies, conducting training, documenting policies, procedures and workflows, trend and reflect impact of activities.
- Monitor, evaluate, educate and implement FEP program requirements related to Utilization Management (UM), Case Management (CM), Medical Management (MM), and Disease Management (DM) activities to areas within the department for appropriate action. This includes tracking daily operations to ensure deliverables are met and reporting information to FEP Director's Office, various internal committees and other audiences as needed.
- Support compliance reviews and audits to monitor adherence with federal and state regulations, FEPDO program rules, Office of Personnel Management (OPM) regulatory guidance, and internal policies and procedures. Ensure that "best practices" are implemented, and observations/findings are satisfactorily resolved.
- Identify and protect FEP assets through a detailed analysis, review, and evaluation of Fraud, Waste, and Abuse (FWA) methodology and best practices consistent with HMSA's FWA program. This includes taking a proactive role in identifying, digesting, and communicating trends and assisting in the coordination of resolution for these trends.
- Performs all other miscellaneous responsibilities and duties as assigned or directed.
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HMSA
Aug 16, 2024 