Hawaii Medical Service Association in Honolulu, HI
Type: Full Time
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, Automated Inquiry, and Enrollment Systems.
Applying practical knowledge of MTM and FEP program requirements and 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.
Perform administrative duties. This includes updating audit database used in tracking reviews, and prepping samples for review ensuring that the data being reviewed is complete.
Keep abreast of changes to HMSA products by reviewing memos and other documentation distributed to the unit as well as changes in MTM Guidelines from the BCBSA.