Medical Management Vendor Relations Analyst

• 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.

• 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

• 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

• Performs all other miscellaneous responsibilities and duties as assigned or directed

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