hmsacareers

Provide strategic and operational leadership for Clinical Review operations Develops and executes strategic plans and provides operational leadership for Clinical Review functions, including Prior Authorization, Prospective Review, Concurrent Review, facility review, inpatient, observation, skilled

Lead and manage the function providing oversight of all matters relating to the maintenance and enhancement of internal operations processes and systems to support HMSA's operational and related programs. Governance and relationship oversight of service providers which includes ensuring all new bene

Clinical Program Support Support implementation and ongoing management of formulary, utilization management, and clinical policy programs within an assigned line of business. Evaluate clinical implications of pharmacy program changes and emerging utilization trends. Maintain alignment between clinic

Initiative Driven Financial & Performance Analysis Conducts deep dive analyses in direct support of specific Medicaid financial performance initiatives (e.g., utilization management strategies, community program investments, benefit or operational changes). Evaluates financial impact, cost drivers,

HRSN Authorization, Eligibility, and Medecision Administration Perform non-clinical eligibility review for HRSN services by reviewing referrals, authorization forms, member eligibility, required documentation, program criteria, and other available information. Create, update, and maintain authorizat

HRSN Reporting, Dashboards & Monitoring Generates required HRSN reporting from available systems, including monthly, quarterly, and ad hoc reports for MQD and internal leadership. Builds, maintains, and refines monitoring dashboards to track referrals, authorization status, utilization, provider cap

HRSN Provider Onboarding, Education & Network Support Serves as the day-to-day point of contact for HRSN providers and community-based organizations participating in or preparing to participate in HRSN service delivery. Supports provider onboarding into HMSA's network, including coordination with in

Effective Program Communication: Provides support to promote effective communication between the compliance and ethics office, employees, contingent workers, and vendors. Responds timely to routine, non-complex inquiries raised through any of the established communication channels; escalate to the C

Mentor servicing representatives to ensure the best customer experience by supporting representatives after they complete classroom training; completing quality assurance audits that ensure timeliness, accuracy, professionalism, and an optimal customer experience; and providing timely, relevant coac

Operational Planning & Execution Manage projects related to developing and improving Pharmacy Operations, coordinate and/or facilitate planning and completion of quality assurance and monitoring activities within the department, Pharmacy Benefits Manager (PBM) and/or among major functional areas Ass

Operational Execution Execute pharmacy operational processes and activities within an assigned line of business. Support implementation of pharmacy benefit, communication, and operational changes. Perform operational tasks accurately and within established timelines. Maintain adherence to department

Provider Pod Leadership Lead recurring Provider Pod meetings for assigned provider organizations. Develop meeting agendas and facilitate productive discussions. Coordinate participation from internal subject matter experts. Track action items and ensure accountability for completion. Aggregate data

Cross-Functional Program Leadership & Execution Lead and drive Pharmacy program intake processes and governance across Pharmacy Management teams and key business partners. Lead and influence communication, alignment, and decision-making among operational, clinical, analytical, vendor, and business s

In-office service contact for assigned groups. Handles day-to-day servicing inquiries directly with account contact via e-mail and phone. Assist with coordination of GTB and certificate requests. Validate the Summary of Benefits Coverage (SBCs), Benefit Summaries, and Summary of Changes that all acc

Coordinates case resolution with internal business areas to respond timely and accurately to provider inquiries regarding claims, benefits and medium complex issues that include medical, or payment policy questions and provider appeals. Resolve root problems to ensure compliance with contract terms

Prepares the financial reporting requirements for the State of Hawaii Insurance Division (DCCA) in accordance with the NAIC Accounting Practices and Procedures manual: Prepares the "Annual Statement" for the Association and ensure timely filing of all required reports. Applies thorough knowledge of

Assessment Triage member to identify medical, psychological, and social barriers to discharge then transition member to appropriate healthcare professional on their team such as TCN or CHW. Care Transition Collaboration Work with healthcare team to ensure safe and smooth member transitions Education

Ensure proper recording and reporting of various financial transactions for the Association and government lines of business. Communicate with other F&A staff and internal departments to record and reconcile the following: Prepare and post accruals for various general ledger accounts on a monthly ba

Ensure proper recording and reporting of various financial transactions for the Association and government lines of business. Communicate with other F&A staff and internal departments to record and reconcile the following: Prepare and post accruals for various general ledger accounts on a monthly ba

Prioritizes approved invoices and check requests according to payment terms. Familiarizes with company policies and navigating steps in Dynamics GP, Certify and CentreSuite. Verifies approver's level of authority to ensure that the cost center and the amount being charged are authorized. Follows thr