Serves as NCQA subject matter expert, ensures health plan compliance and support as it relates to department programs and activities. Initiate, facilitate and coordinate quality improvement activities and metrics to support assigned NCQA standards and requirements. Proactively keep all staff updated on NCQA standards and application, through notifications of change, workf

Direct and oversee all aspects of the Provider Call Center, in alignment with corporate goals and initiatives. Manages, oversees, and evaluates staff. Ensure Provider Call Center performance meets/exceeds Key Performance Indicators by evaluating, analyzing, and interpreting data and metrics. Report on or supervise reporting of KPI metrics. Ensure cross functional collabor

Manage HMSA's social media profiles and presence. Create, manage, and grow HMSA's business presence across relevant social media channels, including, but not limited to Facebook, Instagram, X (formerly Twitter), LinkedIn, Yelp, and YouTube. Evaluate new social media channels for appropriateness and integrate into the HMSA suite of social media platforms. Responsible for s

Financial management and accounting Manages and coordinates work effort for inter plan billing and disbursements functions. Resolves issues related to provider and Host plan payments, refunds, negative balance, deductions, etc. Performs complex financial analysis with minimal supervision and report findings to management. Analyzes financial data for significant fluctuatio

Revise and/or develop medical policies in conjunction with assigned medical director and in accordance with Development and Approval of Medical Policy administrative policy; process includes appropriate and timely implementation and publication. Support MM sponsored meetings by preparing and distributing an agenda, minutes, and documents to be discussed, and taking minute

Establishes relationships with business partners and the IT organization in order to provide technical solutions to meet user needs and influence strategic initiatives. Responsible for leading the analysis of IT requirements, alignment of IT resources and processes in order to meet the clients' organizational needs, as well as the design of enterprise solutions. Responsib

Assists in the implementation of care coordination and nursing duties within the scope of education, knowledge and experience and with appropriate supervision by a physician. Examples of duties include, but are not limited to, measuring and recording vital signs, performing routine screening tests, performing basic lab tests and EKGs, preparing and administering medicatio

Investigator Team Leadership and Support Perform Investigator staff oversight, and coaching on day to day investigation activities including, but not limited to FWA case reviews and approvals, regulatory referrals, documentation, reporting, overpayment processing and prevention. Facilitate and lead Investigator level meetings to resolve operational issues, brainstorm FWA

Leadership Identify, initiate, and manage organization wide projects to ensure that all HMSA's Medicare Program contractual obligations are met or exceeded. Manages necessary changes to existing systems, operations or workflows to address new/revised requirements of CMS/DHS/MQD. Structures work plans and project scope to deliver business impact on high priority issues. Ad

Assist the Credit Union Membership Service Representatives (MSRs) with daily workflow questions, member complaints or difficult inquires, and provides guidance on the interpretation of Credit Union policies and procedures. Coordinates the daily coverage of phones and the lobby area to ensure satisfactory and efficient servicing of our members. The Team Lead is expected to

Performance Pro actively manage a base of accounts by strategically prioritizing account sales and service activities. Get ahead of the curve of known jeopardy accounts by strategically positioning the value in HMSA's solutions. Manage your time effectively to maximize every opportunity to gain HMSA or USAble membership within base customers. Prospect new HMSA groups to g

Coordinate and oversee the preparation of HMSA's monthly financial statements and supporting worksheets. Communicates with other Finance staff and other internal departments to coordinate the preparation and posting of general and standard journal entries into the general ledger. Monitor and upkeep various posting logs. Prepare monthly financial statements and reports for

Prioritizes approved invoices and check requests according to payment terms. Familiarizes with company policies and navigating steps in Dynamics GP, Certify and CentreSuite. Verifies approver's level of authority to ensure that the cost center and the amount being charged are authorized. Follows through with requestor and obtains appropriate approval as needed. Validates

Quality Improvement Operations Provide direction and manage HMSA's overarching Quality Improvement program, including the oversight of staff and necessary resources required to design and implement programs related to compliance with accreditation, regulatory and program requirements (e.g., NCQA, Med QUEST, CMS, OPM, etc.). Oversee project teams and provide guidance to su

a. Project management and facilitation Develops and maintains project plans, timelines, and scope documents for strategy initiatives. Proactively manages deliverables, timelines, and budget Monitors and takes appropriate action to ensure various task and system related deliverables are accomplished in an accurate and timely manner. Develops strategies and tactics based on