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Plan Performance Analyst II

HMSA
United States, Hawaii, Honolulu
818 Ke’eaumoku Street (Show on map)
Sep 23, 2024
Performs operational quality measures as assigned for most lines of business and document errors with limited assistance by: Applying knowledge of HMSA's benefits and their application Reviewing provider contracts/rates and compare them to "Plan Benefits" to ensure that HMSA's payment or denial agrees with both the provider contract terms and member benefits. Applying HMSA's medical policies in equating diagnosis to procedures listed on claims Applying practical knowledge of HMSA's Claims, Customer Service, and Enrollment Systems. Applying practical knowledge of BCBSA guidelines and other requirements of audit procedures Participating in meetings with staff/management in multiple departments to resolve issues raised during the review. (Note: All errors are submitted to the appropriate management from supervisor to executive staff.) Explains exceptions to appropriate management for review and applicable corrections. Audience includes supervisors and managers. Collect and report summary data on the results of the review for reporting to executive staff by performing database queries to gather summary information, and developing conclusions based on the information. Demonstrate ability for critical thinking and apply independent critical thinking. Keep abreast of changes to HMSA products by reviewing memos and other documentation distributed to the unit as well as changes in BCBSA Guidelines. Performs all other miscellaneous responsibilities and duties as assigned or directed