- Responsible for managing day-to-day operations of the Member Advocacy and Appeals Department including the investigation and resolution of cases, compliance with required processes, tracking, reporting, notifications to members and providers of case decisions and determinations, and appropriate case closure for all HMSA lines of business. Interacts with corporate decision-makers (e.g., HMSA Board members, executive and senior vice presidents, and Medical Directors) and providers, intercedes on behalf of members while maintaining the integrity of health plan contracts.
- Directs the development and implementation of Member Advocacy and Appeals policies and procedures to create an effective and efficient operating environment for all HMSA lines of business. Monitors applicable regulations/mandates and identifies potential opportunities and risks. Oversees and directs the development of plans for complying with regulations/mandates and ensures compliance. Drives corporate-wide process improvements identified through members' issues.
- Translates HMSA's vision and mission statement into strategic, tactical, and operational plans for the MAA Department. Develops and maintains these plans to remain consistent with changes in any legislative and agency mandates and HMSA's business strategies and priorities.
- Develops, plans, and maintains the MAA department budget and financial plans based on operational forecasts. Responsible for all MAA department financial expenditures and the monitoring of actual costs related to the yearly budget.
- Assesses the adequacy and effectiveness of the department organizational structure, staffing, resources, technology, and processes and develops action plans for improvement, to include assignment of subject-matter experts in handling appeals for each HMSA line of business (i.e., QUEST Medicaid, Medicare Advantage, self-insured groups, fully insured plans, ACA plans, etc.). Identifies dependencies between the MAA department and other departments; reflects these dependencies in the policies, procedures, and department plans; and communicates any changes to operations to the appropriate parties.
- Manages the MAA department staff, including performance reviews (PMPs) and compensation adjustments, training, guidance, and personal development. Develops performance measurements and communicates expectations to staff. Responsible for hiring and, when necessary, adherence to HMSA processes for determination for dismissal, and assignment of staff to operational duties and project tasks, as necessary. Monitors staff and provide feedback for continual improvement. Responsible for salary changes and consideration, including any increases upon annual review and bonuses.
- Represents the MAA Department on various teams and work groups where appeals/grievances are related or affected, including on-site audits for CMS (for Medicare Advantage), HSAG (for QUEST Medicaid), and NCQA (all HMSA lines of business)
- Performs all other miscellaneous responsibilities and duties as assigned or directed.
- Assists in special projects.
#LI-Hybrid |
HMSA
Dec 05, 2024