Network Management Coordinator

HMSA
United States, Hawaii, Kahului
Feb 04, 2025
Directs and provides guidance to employees responsible for timely and accurate responses to providers' inquiries regarding contracting, claims, benefits and complex issues that include medical or payment policy questions and provider payment reviews/appeals. Develops, implements and maintains operational processes to meet Provider Operations goals, provider contract requirements, compliance with industry standards and Government mandates. They include, but are not limited to Provider Appeals, complaint responses, quality assurance activities, internal audit requirements and Provider Policy Review requests. Supports development and implementation of policy changes on behalf of Provider Ops and communicates the provider perspective when representing the department on cross-functional teams, corporate initiatives and tactical objectives. Coordinates and conducts education activities involving providers, and other HMSA departments with the objective to modify chronic, inefficient claim filing patterns or behaviors. Proactively resolve problems to ensure HMSA's ability to comply with contract terms and resolve problems due to errors with system programming in a timely and accurate manner to ensure strong business relations with all providers. This involves analyzing data to assess the scope of the problem, planning an appropriate approach, influencing business areas to engage their staff in the activity, and measuring results. Work on projects for corporate initiatives; monitors and leads project teams. Responds to provider issues on behalf of HMSA and Provider Ops Management in writing, telephonic, via video and onsite with providers. This includes responses to complaints made through the Insurance Commissioner's office, complex policy inquiries and claim appeals within timeframes required by the Insurance Division or by HMSA as stated in the provider contract. Complaints and appeals must be tracked to ensure compliance by supporting departments such as Claims Administration and Medical Management. Mentor and develop staff to successfully meet the objectives of their PMP; develop, build and sustain positive relationships with the provider community on behalf of HMSA. #LI-Hybrid