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Plan Performance Analyst III

2 months ago

Honolulu, United States HMSA Full time

  1. Audit and review operational quality measures as assigned for All Private Business and/or FEP lines of Business and document errors without assistance and assist other staff in resolving audit issues errors noting the probable cause or causes, impact to HMSA (if applicable) and recommendations for correction. Skills and knowledge required includes:
    • Applying detailed knowledge of HMSA's benefits and their application
    • Reviewing provider contracts/rates and compare them to "Plan Benefits" to ensure that HMSA's payment or denial agrees with both the provider contract terms and member benefits.
    • Ability to apply HMSA's medical policies in equating diagnosis to procedures listed on claims
    • Applying proficient knowledge of HMSA's Claims, Customer Service, and Enrollment Systems.
    • Applying proficient knowledge of BCBSA guidelines and other audit program requirements and procedures
    • Proficient ability to lead meetings with staff/management in multiple departments to resolve issues raised during the review. (Note: All errors are submitted to the appropriate management from supervisor to executive staff.)

  2. Lead in researching issues and explaining exceptions to appropriate management for correction and document management responses. Audience includes supervisor to executive staff.
  3. Assist coordination of monthly/quarterly reporting of results of reviews for reporting to executive staff. Skills required for this task include the ability to perform database queries to gather summary information, and the ability to make conclusions based on it.
  4. Provide training and perform QA reviews as assigned.
  5. Analyze changes in HMSA Products & Business as well changes in Quality measures such as the BCBSA guidelines. This includes evaluating impacts in reporting and identifying changes in audit.
  6. Perform other miscellaneous quality assurance reviews. Includes assisting external clients/auditors in verifying the accuracy of group data.
  7. Performs all other miscellaneous responsibilities and duties as assigned or directed