Job Details

Description

1. Monitor, evaluate, educate, and implement FEP program requirements related to Utilization Management (UM), Case Management (CM), Medical Management (MM), and Disease Management (DM) activities within the department. This includes tracking daily operations to ensure deliverables are met and reporting information to the FEP Director's Office, internal committees, and other relevant audiences.
2. Coordinate cross-functional teams (including HMSA staff, external partners, and providers) to collect, communicate, and distribute information. Conduct quantitative and qualitative analyses to identify opportunities and make recommendations supporting FEP Plan Incentive Program (PIP) metrics and Mahie 2020 strategic goals.
3. Develop methods to enhance daily customer service and claims processing operations and standards. Analyze business problems, recommend system enhancements or redesigns to improve efficiencies, and document policies, procedures, and workflows to monitor and reflect activity impacts.
4. Support daily business operations by compiling and reporting on activities. Identify operational trends, research inquiry escalations, respond to secured messages, and handle administrative tasks.
5. Assist with compliance reviews and audits to ensure adherence to federal and state regulations, FEP program rules, OPM guidance, and internal policies. Implement best practices and address observations or findings satisfactorily.
6. Analyze, review, and evaluate Fraud, Waste, and Abuse (FWA) trends to protect FEP assets, following HMSA's FWA program protocols. Proactively identify and communicate trends and support resolution efforts.
7. Perform miscellaneous responsibilities and duties as assigned or directed.
8. Travel to association-sponsored training programs, meetings, and conferences to stay informed on FEP landscape, industry developments, policy changes, technologies, operational processes, and field strategies.

Qualifications

1. Bachelor's degree and three years of related work experience, or an equivalent combination of education and experience.
2. Basic proficiency in Microsoft Office applications, including Word, Excel, PowerPoint, and Outlook.
3. Valid driver's license, access to an insured vehicle with current registration and insurance.
4. Ability to operate a vehicle safely for off-site business activities.