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.
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
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