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Medical Management Specialist I HMSA
Evaluation, interpretation, and processing of clinical review requests to include but not limited to applying the following requirements:
Validation that requests has met submission requirements based on accreditation / governmental regulation requirements.
Educate and/or communicate with provider offices on appropriate procedures.
Application of internal policies and procedures, contractual provisions, and regulatory requirements.
Multi-system validation of member specific eligibility, benefit and provider requirement for selected service(s) based on member's primary line of business.
Utilization of various resources to confirm HMSA's clinical review requirements; as required, educate and/or respond to provider office with outcome.
Creation of the electronic file within the Utilization Management (UM) management system for review.
Adhering to the guidelines and processes for management of documents within the Fax Manager Application (FMA).
Process vendor authorization files to reflect the appropriate decisions within HMSA's system to appropriately and accurately impact claims processing to include but not limited to the following:
Researching, validate and update existing authorizations based on extensions, peer to peer reviews and updates requested from provider community.
Monitoring and addressing errors as a result of the request program load feature.
Notify and/or communicate issues associated with authorization files with unit coordinator, supervisor or UM Solutions Administrator.
Resolve, document and accurately respond to inquiries, issues or complaints received telephonically from provider (and members) by:
Application of Ulysses Call Strategy servicing skills.
Researching multiple system and/or online document resources
Contacting unit leads or resources for additional explanation.
Triage and transfer calls to appropriate areas upon request or require a subject matter expert (SME).
Escalate calls as appropriate taking into account urgency, customer's level of concern, knowledge required to respond in an accurate manner.
Processing of the Aerial to QNXT (A2Q) error / balance reports by:
Accurately building UMD documents within QNXT to support the claims processing activities.
Notify and/or communicate issues associated with A2Q process to unit coordinator, supervisor or UM Solutions Administrator.
Monitor and processing of clinical review requests received via online authorization tool by:
Applying internal policies and procedures, contractual provisions and regulatory requirements.
Multi-system validation of member specific eligibility, benefit and provider requirement for selected service(s) based on member's primary line of business.
Triaging and distribution of the cases to the respective units taking into account type of service, place of treatment, provider relationship and line of business.
Performs all other miscellaneous responsibilities and duties as assigned or directed.
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Kapolei, HI, US, 96709Posted a day ago Technical Product Manager. HMSA Collaborate with cross-functional teams to understand business needs and translate them into innovative and scalable solution designs that address the unique challenges of the healthcare industry.
Collaboration:
Support Cloud Center of Excellence to identify opportunities for cloud integration and design cloud-based solutions that enhance efficiency, security, and scalability.
Collaborate with architecture, agile teams, and project management office to develop standards, processes, and continuous improvement opportunities.
Support product owners, program managers, solution delivery managers and agile teams for strategic direction, prioritization, and business alignment.
Product Roadmap:
Develop and maintain product roadmaps, ensuring alignment with organizational goals, technology trends, and customer needs.
Drive high level requirements from various stakeholders to align and prioritize needs that will deliver the highest value.
Support and cover for product owners as needed with writing product requirements, prioritizing backlogs, and collaborating with agile teams.
Enterprise Agile Leadership:
Support the Enterprise Agile Initiative, providing strategic direction, fostering a culture of agility, and driving continuous improvement across IT product development.
Support and enable product management lifecycle and agile methodologies across various teams.
Vendor Evaluation:
Evaluate and recommend 3rd party vendor solutions to determine fit with HMSA business capability needs.
Review and approve solutions put forward by our sourcing partners to ensure alignment with product roadmaps.
Performance Outcomes:
Define key performance indicators (KPIs) for products and initiatives, monitor progress, and take data-driven actions to optimize performance.
Performs all other miscellaneous responsibilities and duties as assigned or directed
#LI-Hybrid Honolulu, HI, US, 96814Posted a day ago EMT Basic. Global Medical Response Why Choose AMR ? AMR is one of Global Medical Response's (GMR) family of solutions. Our GMR teams deliver compassionate, quality medical care, primarily in the areas of emergency and patient relocation services. View the stories on how our employees provide care to the world at Learn how our values are at the core of our services and vital to how we approach care, and check out our comprehensive benefit options at Aiea, HI, US, 96701Posted a day ago RN Health Coordinator - $5000 Sign On - Field Based Hawaii. UnitedHealth Group You push yourself to reach higher and go further. Because for you, it's all about ensuring a positive outcome for patients. In this role, you'll work in the field and coordinate the long-term care needs for patients in the local community. And at every turn, you'll have the support of an elite and dynamic team. Join UnitedHealth Group and our family of businesses and you will use your diverse knowledge and experience to make health care work better for our patients. Honolulu, HI, US, 96814Posted a day ago Manager, Vendor Risk Management . HMSA Develops and implements the risk management program in a manner that fulfils the mission and strategic goals of the organization. Complies with organizational policies, state and federal laws and accreditation standards related to corporate compliance, safety, security and risk management. Honolulu, HI, US, 96814Posted a day ago Claims Operation Specialist. HMSA Initiates in the development of strategies and tactics based on logical assumptions and facts considering resources, constraints, and HMSA values. Provides critical assessments of information and data about current trends and issues and actively and openly shares with appropriate parties to encourage collaboration for improvement and change. Translates analysis into solutions and/or options for consideration of specific HMSA actions, including business process improvements. Honolulu, HI, US, 96814Posted a day ago Manager, Disaster Services - O'ahu. American Red Cross Manage the implementation of the disaster services program in an assigned geographic territory based on the regional configuration. Lead and manage a team of local Disaster Program Managers and Supervisors responsible for the implementation of disaster preparedness, response, and recovery programs in the local area. Plan, direct, and implement department, service or program overall strategic goals and objectives. Ensure the development of Disaster leadership volunteers in each of the program support functional areas of the disaster cycle in order to meet the needs of the territory, region, state and division. Responsible for local preparation, response and recovery management as well as management of government partnerships with assigned territory. Drivers for this work include the number of municipalities within its coverage area, the amount and complexity of program activity, presence of significant grant funding, geography, risk, population, frequency of events, and regional structure. Provide support, development and/or leadership guidance to all volunteers. Honolulu, HI, US, 96814Posted a day ago Multimedia Communications Specialist. HMSA Works as or with another videographer/editor to gather video assets, (i.e., conducts on-camera interviews with stakeholders with an ear toward eliciting compelling sound bites, identifies and directs videographers to shoot needed b-roll footage, and conceive graphics). Honolulu, HI, US, 96814Posted a day ago Analyst, Product Development. HMSA Support the development of new products and benefits by performing the analysis and coordinating the efforts of others to produce the necessary information to be used in decision making by HMSA leadership. Produce comprehensive assessments of proposed changes through collaborative efforts with internal partners and subject matter experts. Prepare financial, brand, regulatory, customer, market competitor, provider and other business impact analyses for review during the product development and change process. Prepare product and benefit change analyses and assessments for review during the product development and change process. Present information in a way that emphasizes clarity and assists with understanding and decision-making by the intended audience. Honolulu, HI, US, 96814Posted a day ago Operations Coordinator I.HMSA Evaluate and document the accuracy of various work processes through monitoring/audits. Identify training needs and report to management. Develop, document, and communicate workable, positive solutions, processes, and/or workflows taking into account regulatory, accreditation, service level agreements and the "whole" company perspective. Kapolei, HI, US, 96709Posted a day ago Medical Management Specialist I HMSA |
Kapolei, HI, US, 96709 Apply Now Description
Evaluation, interpretation, and processing of clinical review requests to include but not limited to applying the following requirements:
Validation that requests has met submission requirements based on accreditation / governmental regulation requirements.
Educate and/or communicate with provider offices on appropriate procedures.
Application of internal policies and procedures, contractual provisions, and regulatory requirements.
Multi-system validation of member specific eligibility, benefit and provider requirement for selected service(s) based on member's primary line of business.
Utilization of various resources to confirm HMSA's clinical review requirements; as required, educate and/or respond to provider office with outcome.
Creation of the electronic file within the Utilization Management (UM) management system for review.
Adhering to the guidelines and processes for management of documents within the Fax Manager Application (FMA).
Process vendor authorization files to reflect the appropriate decisions within HMSA's system to appropriately and accurately impact claims processing to include but not limited to the following:
Researching, validate and update existing authorizations based on extensions, peer to peer reviews and updates requested from provider community.
Monitoring and addressing errors as a result of the request program load feature.
Notify and/or communicate issues associated with authorization files with unit coordinator, supervisor or UM Solutions Administrator.
Resolve, document and accurately respond to inquiries, issues or complaints received telephonically from provider (and members) by:
Application of Ulysses Call Strategy servicing skills.
Researching multiple system and/or online document resources
Contacting unit leads or resources for additional explanation.
Triage and transfer calls to appropriate areas upon request or require a subject matter expert (SME).
Escalate calls as appropriate taking into account urgency, customer's level of concern, knowledge required to respond in an accurate manner.
Processing of the Aerial to QNXT (A2Q) error / balance reports by:
Accurately building UMD documents within QNXT to support the claims processing activities.
Notify and/or communicate issues associated with A2Q process to unit coordinator, supervisor or UM Solutions Administrator.
Monitor and processing of clinical review requests received via online authorization tool by:
Applying internal policies and procedures, contractual provisions and regulatory requirements.
Multi-system validation of member specific eligibility, benefit and provider requirement for selected service(s) based on member's primary line of business.
Triaging and distribution of the cases to the respective units taking into account type of service, place of treatment, provider relationship and line of business.
Performs all other miscellaneous responsibilities and duties as assigned or directed.
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