- 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.
- Ensures that program deliverables, documentation, and reporting are complete and meets contractual, compliance, and accreditation requirements.
- 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
#LI-Hybrid