- Fee Reviews
- Lead the Fee Review Process which includes analyzing and explaining complex policy and reimbursement issues to providers, Professional Reimbursement and HMSA leadership
- Prepare cases for Operations Management Committee decision making and for formal Fee Review Committee (practicing physicians) review, communicating with physicians (both verbally and in writing) regarding the outcome and rationale behind decisions and tracking all actions taken to respond to the inquiry to ensure compliance with HMSA's contractual obligations with physicians and to support commitments made to the Insurance Commission Division.
- Network Design, Management and Execution
Participate in the assessment and establishment of network plan to monitor compliance with federal and state regulations, government program rules and sub-regulatory guidance and internal policies and standards. This includes but is not limited to:
- Identify available networks in applicable lines of business (commercial, Medicaid, and Medicare) and programs, and conduct network analysis to establish access and compliance requirements.
- Assess needs and develop project plan(s) including phases, work plans, deliverables and expected outcomes.
- Design network reporting templates or other tools as needed and ensure that program documentation and reporting are complete and meet compliance requirements. Prepare project reports for management, partners, or others as required.
- In collaboration with relevant business areas, gather business requirements to determine network program timeframes, staffing requirements, funding limitations, in addition to ongoing reassessment, reprioritization and/or modifications.
- Manage deliverables and timeline. Direct and/or guide program and network related development activities performed by others. Review status reports prepared by project personnel to ensure project progresses on schedule within prescribed budget guidelines.
- Resolve department project issues or issues assigned by management or team lead. Identify organizational strengths and weaknesses and suggests areas of improvement. Develop functional specifications and system design specifications for program development opportunities. Review and edit requirements, specifications, business processes and recommendations related to proposed solution.
- Identify root causes of non-compliance, deficiency, or other irregularity.
- Report on findings and observations, and corrective action plans.
- Recommend improvements of varying complexities to strengthen operations in meeting network standards.
- Participate on cross functional teams as a member or team lead.
- Network Monitoring and Oversight
- Maintain and execute system for maintaining necessary documentation related to network access and compliance monitoring activities.
- Provide oversight and provide department leadership on regular status reports on network monitoring activities.
- Conduct process measurement review and analysis, program evaluation(s) and/or statistical analysis as needed.
- Directs others to conduct data analysis or abstraction as needed.
- Requirements Deliverables
- In collaboration with relevant HMSA internal teams, monitor and analyze new laws, rules, regulations, and guidelines as well as changes to existing rules & regulations related to network management.
- Convert statutory language to network requirements for business areas.
- Provide timely response to RFPs and ensure compliance with new laws, rules, regulations, and guidelines for HMSA's provider network.
- Performs all other miscellaneous responsibilities and duties as assigned or directed.
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HMSA
Jan 07, 2025 