Medical Management Vendor Relations Analyst

2 days ago


Honolulu HI United States HMSA Full time
  1. Coordinate and manage deliverables of aspects of utilization management programs by delegated vendors:
    • Ensures that program deliverables, documentation, and reporting are complete and meets contractual, compliance, and accreditation requirements.
      • Develops data templates and submission forms.
      • Maintains program documentation for auditing purposes.
    • Analyzes business issues, including but not limited to new services, contract deliverables, enhancements, etc.
    • Troubleshoots workflow issues as well as member/provider complaints and recommend solutions to management and internal departments.
    • Reviews status reports to ensure projects progress on schedule within prescribed guidelines. Modify plans as required. Prepares project reports for management, partners, or others as required.
    • Identifies and implements opportunities for process improvement in workflows and infrastructure operations. Initiate change and evaluate impact.
  2. Program interaction/Committee involvement
    • Presents vendors' UM program description, program evaluation, and delegation oversight audit reports to HMSA's cross-functional committees
    • Meets regularly with vendor's operational areas to assist with oversight of the vendor program and services
    • Provides coordination and guidance to other departments and external resources in managing work to support efficient program operations.
    • Leads coordination of internal cross-departmental meetings
    • Provides training and consultation to vendor staff on an as-needed basis
  3. Subject matter expertise on program compliance
    • Facilitates quarterly UM file reviews with Medical Director's guidance
    • Acts as a liaison between vendors and HMSA departments for various audit activities
    • Coordinates with vendors to ensure timely and accurate reporting of UM decisions as required by state and federal agencies
    • Provides subject matter expertise in evaluating vendors' compliance with NCQA UM standards
    • Prepares vendors' documentation in consultation with Quality Improvement department for submission to NCQA during re-accreditation surveys
  4. Performs all other miscellaneous responsibilities and duties as assigned or directed
#LI-HybridRequiredPreferredJob Industries
  • Other


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