Conducts critical analysis of highly complex and sensitive member and provider appeals, inquiries and grievances and applies internal policies and procedures, contractual provisions, and regulatory requirements.
Secures information from internal and external resources to resolve issues.
Assists Supervisor and Coordinator in working as a liaison with providers, members and internal decision makers in representing HMSA objectives, goals, and expectations for meeting contractual, regulatory, and accreditation requirements.
Negotiates/resolves sensitive issues with internal and external parties.
Takes all facts and research from internal and external resources and presents a full explanation of the member's or provider's position and concerns to management and decision makers.
Triages cases to resolve them upon initial inquiry to best service the member as well as minimize the number of cases escalated to senior management and executives.
At the direction and supervision of management, participates on cross departmental committees and other internal meetings to identify, clarify, research, and resolve inquiries and issues.
Identifies when changes to policies and procedures are needed based on case resolutions, statutory or regulatory changes, or accreditation requirements.
Proposes changes to management based on identification and analysis.
Analyzes and identifies issues that may require multiple department efforts to resolve.
Presents recommendations to internal committees, subgroups and executive management for decision making purposes as it relates to cases after discussion and approval from Supervisor and Coordinator.
Assists with the implementation of resulting decisions for change/resolution.
Assists supervisor/manager in responding to internal investigations, reviews, and audits; regulatory inquiries; and accreditation related audits.
Assist internal customers with complex member/physician inquiries with guidance and direction from management.
Identifies member problems, member education needs, or trends and report these to manager, as well as recommend resolution. Takes a proactive role in reviewing, digesting and communicating any new regulation, standard, business change, etc. affecting the member advocacy and/or appeals process. At direction of management, assists in the coordination of changes among departments.
Performs quality assurance of case documents and assists Supervisor and Manager with various corporate activities.
Performs all other miscellaneous responsibilities and duties as assigned or directed.