HMSA jobs - 72 jobs

Data Management: Reviews data sources and preps needed data. Identifies existing and new data sources. Performs data prototyping, if necessary, to agree what data can/not be used. Preps data for use in analysis, goes back to source if problems are found, and identifies other options/alternatives if problems cannot be resolved. Performs review of data to ensure completeness/accuracy/timeliness for the purpose of the analysis. Maintains tables that are necessary for department or corporate reporting. Ensures existing, approved, corporate tools used can accept/integrate the data. Analytics and Technical Acumen: Performs required analysis, applies accepted statistical methodologies where applicable, and documents the process that was followed, and data sources/tools used. Determines what kind of analytics will be performed (descriptive, predictive, prescriptive) and defines/documents overall framework. Understands various internal and external data sources available; uses expertise to utilize the most appropriate data source. Utilizes appropriate tools to load, integrate, and analyze data. Conducts analysis and documents findings, identifies unexpected anomalies and root cause (if possible) and determines if analysis can continue, identifies alternatives if anomalies cannot be resolved. Ensures reproducibility of outcomes. Documents entire analysis process, including business problem, data sources, methods and tools used, project reference, and outcomes. Implements pre-emptive actions, where possible. Analytics/Reporting Tool Development & Training: Participates in the development and delivery of analytics/reporting tools for internal and external customers. Types of projects include the development and or maintenance of self-service reporting tools and regular or ad hoc reporting. Applies a whole company perspective, draws upon previous knowledge and experience, and -- where necessary -- research new/other approaches to identify and agree upon objectives, approach, and success measures. Defines delivery milestones and negotiates timeframes, monitors progress and periodically notifies customer of status. Provides training to customers on new tools/reporting capabilities Effective Communication: Prepare/present findings that are informative and audience appropriate. Reviews findings and outcomes with customer, ensures business problem/objectives have been met, and prepares documentation of the analysis. Where necessary, manage divergent views in the audience and advises the internal/external customer on any recommendations or options that will facilitate data and analysis driven decision making. Prepares a presentation of the analysis, process followed and reviews it with the customer to ensure the results are audience appropriate. Performs all other miscellaneous responsibilities and duties as assigned or directed. #LI-Hybrid

Responsible for operating and providing support to various applications within HMSA's infrastructure. Responsibilities include, but are not limited to the following: Analyzes production storage usage and recommends modifications as appropriate (storage). Assists with storage requirements definition and acquisition for projects (storage). Coordinates and implements storage requests, backup schedules, and file restoration activities (storage). Plans, schedules and coordinates implementation of storage and backup solutions (storage). Loads, configures and maintains servers, including assistance with server requirements definition and implementation for projects (server). Analyzes and troubleshoots server problems and issues (server). Plans, schedules and coordinates implementation of server upgrades, patches, and tools (server). Configures and installs desktop PCs, peripheral equipment, laptops and other mobile devices. Performs conversions from desktop to laptop. Coordinates port movement and network access issues. Documents procedures for performing configurations and conversions from desktop to laptop. Provides input regarding port availability, equipment locations, device installations and service during project planning and requirements phase for office moves/adds/ changes. Reviews plans for accuracy. Coordinates the deployment of new images, software/hardware upgrades and fixes. Makes suggestions for design of standard set of integrated products (standard image) by recommending hardware and software products to meet user requirements. Sets up accounts under the local domain and assists with Internet access. Assists external users with dial-up access problems. Coordinates and sets up access or service accounts such as Internet and Email. Is aware of service level agreement targets. Explains service procedures to users. Monitors service level agreements regarding desktops to ensure that requirements are met or exceeded. Escalates problems as required based on SLAs. Informs management as appropriate. Troubleshoots problems. Identifies severity of problem and escalates when necessary. Coordinates with users and other IT resources for problem resolution or works with vendor technical support to resolve client problems. Builds checklists and scripts. Determines if loaner PCs are needed. Updates users on trouble ticket status. Ensures follow up on problems with users. Plans, schedules and performs hardware and software repair and installations. Calls in and coordinates all repairs that deal with outside vendors. Documents problem status and resolution in tracking log. Alerts team members about recurring problems. Provides on-the-spot training to users. Evaluates events log and resolves problems as needed. Administers security procedures. Unlocks or sets passwords as needed. Reports security issues when appropriate. Assists users with desktop recovery issues. Participates in integration testing. May design and lead integration testing. Assists in video conferencing activities. Works with vendors with initial setups and learns procedures. Complies with fixed asset and disposal procedures. Performs system administration functions required for daily operations (server). May research and evaluate software/hardware products and industry trends to assist in project development. Participates in Technical Review Committee (TRC) to ensure enterprise-wide standardization. May define staff schedules and prioritizes work. Provides after business hours support, as needed. Mentors less experienced staff. Performs all other miscellaneous responsibilities and duties as assigned or directed. #LI-Hybrid

Responsible for managing all aspects of the planning, execution, controlling, and closure of projects/programs. Responsibilities include, but are not limited to, the following: Receives high-level business requirements and develops detailed requirements. Prioritizes efforts and maintains and manages inter and intra project dependencies. Refines resource requirements and forms project teams. Further defines estimates for financial, physical or human resources to support long-term projects and programs. Champions the development of best practices, project standards, procedures and quality objectives across multiple projects/programs and organizations. Utilizes established project standards, procedures and quality objectives. Conducts project kickoff meetings, communicating individual roles and project/program expectations and ensuring that all project team members have the tools and training required to perform effectively. Integrates detailed project plans and schedules into a master program plan. Provides work direction and leadership to assigned programs, including scheduling, assignment of work and review of individual project efforts. May manage project/product leads. As needed, facilitates the evaluation, selection and contract negotiation for external vendors and independent contractors. Manages relationship with external vendors working to support project requirements. Assesses performance against project milestones/schedule, metrics, scope, quality as defined by contract specifications. Acts as liaison between business client and vendor. Makes presentations to solicit program buy-in, report on project status, conduct problem resolution and other types of communication to a variety of audiences. Monitors program milestones and critical dates, scopes, cost and quality to identify potential risks. Initiates ways to resolve schedule and other project-related issues. Keeps management aware of the situation. Manages any effects on related projects. Assesses variances from the program and project plans, integrates metrics, and develops and implements changes as necessary to ensure that the project remains within specified scope and is within time, cost and quality objectives. Ensures that business owner and/or project executive sponsor has a process to track outcome and satisfaction metrics. Manages effects on related projects. Conducts project review and closure at project completion to confirm acceptance and satisfaction of the program and each related project. Continuously provides the team with constructive feedback as it pertains to project or overall program performance. Works with development team to integrate areas of improvement into the systems development life cycle and project management processes. Develops and maintains a productive working relationship with program stakeholders. Coaches or mentors less experienced personnel. May conduct performance reviews and career planning sessions. Performs other duties as assigned. One example of this would be to personally manage projects when such a need arises. #LI-Hybrid

Provide guidance to team members; ensure assigned Group Underwriters are able to deliver the rate renewal/RFP information necessary to support the Account Planning process. Ensure all rating staff is adequately trained in the statistical reporting structure, financial accountability in the book of business concept, data mart use, and all other tools/concepts necessary to complete rate proposals. Oversee the work of the unit and maintain responsibility for his/her own book of business. Work to ensure HMSA maintains positive relationships with its most important clients by performing accurate rating analyses for the organization's largest politically sensitive accounts and/or accounts with the most complex financial arrangements. Partner with Strategic Account Managers to acquire/retain accounts pivotal to the organization by attending customer meetings as a subject matter expert, communicating complex underwriting concepts to external decision makers in simple and understandable language. Monitor effectiveness of workflow and make changes as necessary. Supervise work of the unit staff to prepare rate filings for submission to the Insurance Division. Track and report on status of filings. Ensure the appropriate and timely response to verbal and written inquiries from the Insurance Division. Responsible for implementing legal, structural or system changes in the rating unit, which can be driven by legal requirements such as Affordable Care Act regulations or system upgrades such as front end system replacements. Develop and deliver necessary modifications based on system changes or new underwriting methodologies. Articulate necessary underwriting report and data impacts and requirements due to external changes. Keep upper management apprised of any current or expected changes that have extensive impact. Train staff. Provide training on new workflows and procedures. Update templates and create new procedures for the rating staff. Check and audit work of the unit. Answer standard and complex questions from the accounts and AMS (Account Management and Sales department) on rate renewal methodology and calculations, as well as financial and statistical reports. Complete performance evaluations for assigned staff; screen, interview and hire applicants when positions are open. Perform other duties as assigned or directed. #LI-Hybrid

Manage community health by establishing and maintaining trusting relationships with individuals, families, and providers to promote health, recovery, resiliency, and wellness. Advocate and support members and their families by prioritizing their needs and preferences, making sure they receive appropriate care and services promptly. Coordinate and collaborate with licensed clinicians and/or Health Management programs, as needed. Adjust workflows when necessary to provide optimal care for each situation or individual. Uses effective communication techniques, including motivational interviewing, to encourage members to attend regular provider appointments, close open care gaps, and utilize medical services that support their health. Engage with members and their families to discuss major health concerns and explore solutions to obstacles impacting service delivery, member satisfaction, cost, and community health. These efforts contribute to better care coordination for members overall. Delivers comprehensive education, resources, referrals, and connections to health-related services within the community. Facilitates the introduction of new or underutilized programs and services to community members. Provides guidance to community members facing complex health cases in navigating healthcare systems. Responsibilities may include, but are not limited to, conducting home visits, accompanying individuals to appointments, and supporting community events as needed. Exercises sound professional judgment and adhere strictly to scope and licensure boundaries to ensure actions are taken in the best interest of the community member(s). Provides culturally appropriate health education and instructions on using existing health and social services, presenting information clearly and effectively. Performs all other miscellaneous responsibilities and duties as assigned or directed. #LI-Hybrid

Utilize medical necessity criteria from established medical policies and clinical practice guidelines to render precertification determinations as described in the Medical Management UM work plan. This detailed clinical judgment includes evaluating whether the requested service is a covered benefit under the member's health plan, is medically appropriate for the member's clinical condition or whether the request requires referral to a Medical Director for potential denial of the request. The Nurse Reviewer must follow each line of business' requirements and each accrediting body's (CMS, NCQA, HSAG) requirements for each request. Assists on inquiries from external parties such as the State Insurance Commissioner and from the Legal Department. Responsibilities include, but are not limited to: Demonstrate understanding and application of over 250 Guide to Benefits, Evidence of Coverage, Plan Brochure, and Member Handbook. HMSA annually updated medical and drug policies, medical protocols, National Comprehensive Cancer Network, Milliman Care Guidelines, Drugdex, etc. to determine the medical necessity of urgent and non-urgent precertification requests. Urgent requests must be completed within 72 hours and non-urgent requests within 15 calendar days. Use clinical judgment, medical necessity guidelines and plan benefits to determine approval, potential denial or alternative treatment of each urgent or non-urgent precertification request. Settings include inpatient, outpatient, in-state, out-of state and out-of country. Document clinical case summary and review outcome of each review appropriately to meet regulatory and program requirements. Review various types of services, including but not limited to: Transplants Air Ambulance Chemotherapy Clinical trials Genetic testing Cancer treatments/radiation therapy Experimental/Investigational Services/Devices New Technology Utilize medical necessity criteria from established medical policies and clinical practice guidelines to render precertification determinations as described in the Medical Management UM work plan. This detailed clinical judgment includes evaluating whether the requested service is a covered benefit under the member's health plan, is medically appropriate for the member's clinical condition or whether the request requires referral to a Medical Director for potential denial of the request. The Nurse Reviewer must follow each line of business' requirements and each accrediting body's (CMS, NCQA, HSAG) requirements for each request. Assists on inquiries from external parties such as the State Insurance Commissioner and from the Legal Department. Responsibilities include, but are not limited to: Call providers when additional clinical information is required to clarify or complete a complex precertification determination. Approve precertification requests based on clinical judgment using criteria, medical record documentation and other information received from the provider. Consult with Medical Directors on requests which do not meet clinical criteria and offer alternative covered health care options as appropriate. Consult Medical Directors on potential quality issues identified during review of medical records. Refer cases to Integrated Health Management, Pharmacy Department or Benefits Integrity Department depending on the concern. Evaluate suspended claims against medical records to determine the medical necessity and appropriateness of medical services, identify irregularities such as over or under-utilization of services, potential up-coding, over billing, etc. Communicate timely, accurate information either verbally, electronically or in writing using clinical judgment, knowledge of medical/reimbursement policies and plan benefits to providers, members as well as internal MM staff and other internal departments (Claims Administration, Customer Relations, Provider Contracting, etc.). For denied services, ensure the denial, benefit and appeal language are accurate and consistent with department procedures, accreditation and regulatory guidelines. Identify and refer members with specific medical and/or behavioral health needs or complex case management and collaborate with medical and behavioral case management staff. Identify and refer quality of care issues and suspected fraud, waste or abuse to the appropriate departments. Perform pre-screening assessment of incoming pre-certification requests to ensure appropriateness of review. Advises non-clinical staff on clinical and coding questions to ensure correct system processes and entries. Performs all other miscellaneous responsibilities and duties as assigned or directed. #LI-Hybrid

General Administrative Support Relieves the CEO/assigned Executive(s) of majority of administrative functions and tasks, ensuring the most effective/efficient use of the Executive's attention and focus. Drafts routine and specialized correspondences on behalf of the CEO/assigned Executive(s). Receives, reviews and determines the appropriate parties to channel/direct sensitive, proprietary, and confidential matters to. Actively follows up on the status of pending issues, conducts independent research on subject matters related to Executive's business areas and corporate position, and when appropriate responds independently on behalf of the executive in a timely manner. Responsible for the inventory of supplies on the Executive floor. Internal/External Contacts Coordinates and hosts a variety of internal and external visitors. Receives, escorts, and announces internal/external visitors to the Executive offices. Resolves meeting or event conflicts. Exercises independent judgment when prioritizing communications and determining urgency, escalation needs, and appropriate contact with CEO/assigned Executive(s). Assesses situations and interrupts CEO/assigned Executive(s) schedule for issues/situations that the Executive Assistant determines require immediate action. Answers and routes phone calls appropriately. Meeting/Calendar/Travel Oversees and maintains the calendar for CEO/assigned Executive(s) in highly organized and efficient manner. Evaluates and prioritizes appointments and meetings based on urgency and business impacts, adjusting as needed. Ensures CEO/assigned Executive(s) have an appropriate amount of time to effectively meet various obligations. Books venue(s) for meetings, creates agendas, obtains relevant handouts/brochures, and procures refreshments for the meeting. Maintains a global view of scheduling, efficiently and effectively coordinates with other assistants for meetings that require multiple Executives. Arranges and books complex multi leg itineraries for executive or assigned parties as required. Corporate Communications Monitors and manages the corporate communications channel for CEO/assigned Executive(s). Ensures the timely and accurate flow of information to and from the executive offices including but not limited to marketing initiatives, policy/procedure updates, corporate communications, and any other item that have companywide impact. Prepares and modifies presentations and responses for both internal and external audiences. Acts as a liaison by planning and scheduling across various communication channels to ensure all internal and external parties are well informed. Responds independently to complex matters of significance impacting business goals and outcomes. Special Projects Lead/coordinates internal and external special projects and community engagement activities, simple to complex in nature, based on Corporate goals or initiatives. Researches and evaluates vendors, obtains and reviews RFPs, conducts cost-benefit analysis, negotiates and enters into contracts for products or services on behalf of HMSA ensuring selection of the best vendor/contractor to meet project objective. Efficiently guides vendors/contractors through the Contract Vendor Management (CVM) process. Provides direction and guidance to volunteer staff and external vendors. Also responsible for miscellaneous support tasks during projects/events. Budgeting & Purchasing Reviews and approves purchase orders and invoices within assigned signing powers/levels. Acts as a liaison with various departments to ensure financial, budgeting, and accounting procedures are being followed, and authorizations are obtained. Performs all other miscellaneous responsibilities and duties as assigned or directed.

Claims Resolution & Support Serve as the primary liaison for complex escalated claim inquiries from providers, members, account management, and internal departments. Research and resolve complex claim discrepancies, denials, adjustments, and payment issues within established service-level agreements (SLAs). Coordinate with claims examiners, configuration, and payment integrity teams to ensure accurate claim adjudication. Document and maintain claim processing instructions and workflows to ensure accurate and efficient processing. Provide guidance and mentoring to Claims Liaison Specialists. Analysis & Reporting Perform root-cause analysis of claim errors, payment delays, and provider/member complaints. Compile and present findings to leadership with recommended solutions. Track claim trends and prepare reports on recurring issues, financial impact, and compliance risks. Stakeholder Communication Provide clear and timely communication of claim resolutions to providers, members, and internal stakeholders. Develop strong working relationships with provider relations, customer service, utilization management, and network management teams. Function as a subject-matter resource on claim workflows and policies. Process Improvement & Compliance Identify opportunities to improve claims workflows, system configuration, and provider/member experience. Participate in cross-functional workgroups to implement corrective actions and process enhancements. Ensure adherence to state, federal, and accreditation guidelines (e.g., CMS, HIPAA, NCQA). Performs all other miscellaneous responsibilities and duties as assigned or directed. #LI-Hybrid

Manage staff, ensuring provider inquiries are responded to timely, accurately, and professionally. Resolve complex provider inquiries. Respond to and oversee staff responding to CMS demand letters. Participate in ad hoc projects to help enhance the provider experience with HMSA. These may include but are not limited to enhancements of provider online resources and development of content for the HealthPro news and Provider Resource Center. Analyze relevant data sources to proactively help identify and resolve issues affecting providers. Oversee training activities and the creation of training materials, workflows, and desktop procedures. Prepare and conduct presentations for staff and management. Develop staff in a manner that ensures continual growth and opportunities while maximizing efficiency for providers and the department. Integrate Claims Adjustment Specialists into the Research and Correspondence unit by implementing a plan for the pend resolutions to be worked and ensuring audit compliance. Lead the Research and Correspondence team in technological initiatives including existing application upgrades, adopting new applications, and ongoing refinement of the team's use of the SalesForce application. Coordinate reporting requirements for the unit including but not limited to inventory management reports and ad hoc claim queries. Performs all other miscellaneous responsibilities and duties as assigned or directed. #LI-Hybrid

Responsible for analysis, design, development, integration, maintenance and support of applications. Responsibilities include, but may not be limited to, the following: Participates in the project planning and analysis process with clients, business analysts and team members. Assist in sizing and the development of timelines. Identifies and refines system requirements. Complies with architecture processes, principles, policies and standards. Assists in buy vs. build recommendations. May provide input into evaluation of system options, risk, cost versus benefits, and impacts on business processes and goals. May evaluate and provide recommendations for application packages. Designs moderately complex solutions. Develops technical specifications for applications. Makes recommendations for the development of new code or reuse of existing code. May identify best sources of data and works with data architects to ensure feasibility with corporate data sources, when needed. Able to extract data from multiple sources. Able to design and implement complex data transformations. Able to load transformed data into information management system. May adjust processes to maximize efficiency of business user queries. Utilizes development platforms, middleware tools and software frameworks for designing and developing solutions when required. Develops or modifies application components using disciplined software development processes. Complies with quality standards and procedures. Participates in software inspections and quality reviews. Uses modern testing practices, builds unit tests and conducts testing to ensure application meets specifications. Implements and executes integration test plans with team. Documents new or modified components, testing activities/results and other areas such as application-wide error handling and backup/recovery procedures. Provides ongoing maintenance of applications. Analyzes existing applications to identify and document opportunities for improvements. Prepares releases for test and production. Validates deployment once released and communicates the change to stakeholders. Provides Tier II (application) support. May provide Tier III level support. Troubleshoots existing systems to identify errors or deficiencies and develops solutions. Delivers solutions as part of a team utilizing agile or waterfall methodology as applicable. Provides feedback for team to improve in feedback sessions and/or retrospectives. Provides technical coaching and mentoring to less experienced team members. Performs all other miscellaneous responsibilities and duties as assigned or directed. #LI-Hybrid

Accurately calculate and analyze a variety of employer group rates using the historical utilization of the account. Extract and analyze historical data of the account to ensure accuracy and good logic. Analyze the overall composition of the group to ensure that the total risk is not excessive. Produce and audit rate renewals, rate filing worksheets, and exhibits for moderately complex to very complex accounts using pre-established guidelines and templates as a basis for analysis, performing necessary additional research on issues that fall outside these guidelines. Will modify guidelines and templates as needed. Answer complex underwriting questions from accounts and Marketing Department on rate renewal calculations and various financial arrangements. Provide consultation to Account Management and Sales and explain rationale and rating practices for highly complex accounts to assist in rate renewal process. Collaborating with the Underwriting team and account management team to ensure rates and financial options are appropriate. Accurately prepare, analyze, and audit other reports as required by account (5500, utilization reports, financial reports, financial accountings, financial statements, etc.). Prepare, analyze, and reconcile monthly billings for self-insured accounts based on the terms of the contract with the account. Answer moderately complex to complex underwriting questions from Account Management and Sales Department on statistical and financial reports. Produce and audit other data as needed to support the Account Planning process. Analyze and prepare rate proposals for prospective accounts based on information provided and recommend best course of action. May accompany Account Management and Sales staff to client meetings to answer questions and provide additional underwriting information when needed. Update and maintain rating and reporting system. Research and resolve data problems when they arise. Identify, research, track, and report paid/unpaid case amounts as needed. Prepare and audit monthly recovery reports with supporting documentation and respond timely to open queries. Aggregating and organizing data submissions and narratives for reinsurance audits and reinsurance renewal submissions. Deliver training and coaching to other underwriting colleagues. Leading input on efforts to support best practices for the department and HMSA. Participate in special projects. Perform all other miscellaneous duties and responsibilities as directed or assigned. #LI-Hybrid

Independently process group and direct payments received from walk-in members and groups while providing all customers with an exceptional customer-focused and positive HMSA Center experience. Ensure that the experience meets the customer's needs and exceeds their expectations. Communicate and promote HMSA's brand message and commitment to service excellence. Effectively and independently analyze and research inquiries from customers (internal and external) relating to billing and payments processed by cashiers. Handle customer inquiries (internal and external) by responding to their needs quickly and efficiently. Requires broad understanding of HMSA's business, including the Hawaii Health Connector, HMSA online storefront, LRSP, QNXT, and ancillary systems. Provide quality service in line with HMSA's mission and vision. Assist in bill production for individual subscribers and groups, including cycle billing and demand billing. Performs reconciliations and audits to ensure the billing system, A/R system, and electronic bill presentment system are in balance. Independently resolves any identified variances. Process mailed-in group and direct payments from members and groups. Process rejected and unprocessed payments from Bank of Hawaii Lockbox. Process miscellaneous payments from other departments: Medicaid, Workshops, Administrative Services Only, Long Term Care, etc. Process medical refund checks (HMSA or other) mailed-in by members and providers. Process miscellaneous checks from Finance & Accounting units. Process member Automatic Dues Payment Set-up (DPS) and mailing notification letters. Process QNXT Unapplied Cash Payments. Balance and reconcile deposits, and record payments to various general ledger accounts. Review and conduct analyses to assist the department in maintaining an efficient delinquency and cancellation process for individual subscribers and groups. Includes monitoring delinquent subscribers and groups, generating and mailing delinquency and cancellation letters, and ensuring that cancelled accounts are reconciled accurately. Process routine enrollment and group or subscriber maintenance transactions submitted in the HMSA Centers. Processes returned checks, agent fee bills, and issues petty cash. Balance cash daily and replenish till monthly. Record expenses to proper operating expense general ledger account. Make corrections as needed. Performs all other miscellaneous responsibilities and duties as assigned or directed

Product Ownership & Agile Delivery: Develop, maintain and communicate product vision & roadmaps, ensuring alignment with organizational goals, technology trends, and customer needs. Represent the voice of the customer and business stakeholders within the Scrum team, ensuring user stories deliver measurable value. Own and evolve the product backlog, prioritizing based on performance analytics, stakeholder input, sprint outcomes, and shifting business priorities to maximize value delivery. Partner internal teams to ensure timely and high-quality deliverables. Facilitate cross-functional collaboration between developers, QA, UX, and architecture to align on technical feasibility, design standards, and user experience goals. Support release planning and deployment coordination across environments. Product Strategy & Requirements: Translate business needs and strategic goals into innovative, scalable solutions aligned with healthcare industry challenges and regulatory requirements. Apply business insight and analysis to develop strategies that reflect constraints, resources, and HMSA values. Define and document product features and user stories that reflect strategic objectives and adhere to architectural standards Continuously improve processes, templates, and methodologies to enhance customer experience, quality, and launch time. Stakeholder Management: Build strong relationships with stakeholders at all levels, ensuring alignment on needs and clear communication throughout the product development lifecycle. Level set stakeholders' expectations and facilitate collaboration to define and deliver feasible product visions. Act as primary liaison between business stakeholders and development teams, leading and mentoring stakeholders on product lifecycle, processes, and tools. Present and communicate with executive level leadership Collaboration: Partner with internal teams to develop standards, processes, and continuous improvement opportunities. Support product owners, program managers, and other teams with strategic alignment and prioritization. Mentor product team members and create product tools, templates, and processes. Performance Outcomes: Define and monitor key performance indicators (KPIs) for products and initiatives, using data to drive optimization. Performs all other miscellaneous responsibilities and duties as assigned or directed. #LI-Hybrid

Corporate Compliance Training Administration Manage the training database for employees and temporary workers/contractors with the assignment of administering onboarding and annual continuing education training; follow-up on overdue assignments; ensure accuracy of demographic information into the database; prepare regular status reports. Troubleshoot and propose solutions/recommendations. Resolve problem reports and issues. Recommends improvements for efficiency in procedures. Administrative Support Perform administrative functions for management teams including scheduling and arranging internal and external meetings; preparing travel arrangements for conferences, meetings, seminars; assisting with expense reports, invoice processing, and check requests; routing mail; processing print requests, and access requests. Compliance Office Support Support routine operational functions and projects including but not limited to: Initial review, analysis of required action (and triaging when appropriate), compose responses that address all concerns raised, and timely closure of routine cases in compliance tracking system Collection, review, tracking, and follow up procedures to ensure all necessary compliance documents are obtained for temporary workers. Organize and implement Compliance & Ethics Week activities. Enterprise policy management, including tracking and follow up with external stakeholders to support regular and timely review and approval. Committee Support * Manage the administrative duties for the planning and execution of compliance committees, including the Audit & Compliance Committee of the Board of Directors, C&E Advisory Committee, Compliance Operations Committee and other subcommittees. Manage sensitive corporate files (by-laws and corporate documents). Coordinate meetings, including notification of meetings to members, coordinating site arrangements, assembling meeting materials, managing pending agenda items and conducting meeting reminder notices (phone or mail). Assisting with preparing and drafting presentation materials, uploading to the appropriate sites and applications, and preparing accurate and complete minutes. Manage administrative duties for external audits including preparing and coordinating for onsite examinations. Performs all other miscellaneous responsibilities and duties as assigned or directed. #LI-Hybrid

Provide strategic management and direction for the configuration of health plan products, provider networks, and reimbursement methodologies to ensure alignment with business requirements, state and federal regulations, and accreditation standards. Develop and implement policies, standards, and governance frameworks for configuration accuracy, quality control, and compliance. Collaborate with external partners, IT, Claims Operations, Provider Services, Compliance, and Product teams to ensure system configurations support new products, regulatory changes, and organizational initiatives. Lead testing, validation, and sign-off processes for new configurations, system upgrades, and change requests Drive process improvements and automation opportunities to enhance configuration efficiency and reduce errors. Serve as a subject matter expert (SME) for configuration management, providing training, guidance, and mentorship to internal and external team members and business stakeholders. Performs all other miscellaneous responsibilities and duties as assigned or directed.

* Utilize medical necessity criteria from established medical policies and clinical practice guidelines to render precertification determinations as described in the Medical Management UM work plan. This detailed clinical judgment includes evaluating whether the requested service is a covered benefit under the member's health plan, is medically appropriate for the member's clinical condition or whether the request requires referral to a Medical Director for potential denial of the request. The Nurse Reviewer must follow each line of business' requirements and each accrediting body's (CMS, NCQA, HSAG) requirements for each request. Assists on inquiries from external parties such as the State Insurance Commissioner and from the Legal Department. Responsibilities include, but are not limited to: * Demonstrate understanding and application of over 250 Guide to Benefits, Evidence of Coverage, Plan Brochure, and Member Handbook. HMSA annually updated medical and drug policies, medical protocols, National Comprehensive Cancer Network, Milliman Care Guidelines, Drugdex, etc. to determine the medical necessity of urgent and non-urgent precertification requests. Urgent requests must be completed within 72 hours and non-urgent requests within 15 calendar days. * Use clinical judgment, medical necessity guidelines and plan benefits to determine approval, potential denial or alternative treatment of each urgent or non-urgent precertification request. Settings include inpatient, outpatient, in-state, out-of state and out-of country. * Document clinical case summary and review outcome of each review appropriately to meet regulatory and program requirements. * Review various types of services, including but not limited to: * Transplants * Air Ambulance * Chemotherapy * Clinical trials * Genetic testing * Cancer treatments/radiation therapy * Experimental/Investigational Services/Devices * New Technology * Utilize medical necessity criteria from established medical policies and clinical practice guidelines to render precertification determinations as described in the Medical Management UM work plan. This detailed clinical judgment includes evaluating whether the requested service is a covered benefit under the member's health plan, is medically appropriate for the member's clinical condition or whether the request requires referral to a Medical Director for potential denial of the request. The Nurse Reviewer must follow each line of business' requirements and each accrediting body's (CMS, NCQA, HSAG) requirements for each request. Assists on inquiries from external parties such as the State Insurance Commissioner and from the Legal Department. Responsibilities include, but are not limited to: * Call providers when additional clinical information is required to clarify or complete a complex precertification determination. * Approve precertification requests based on clinical judgment using criteria, medical record documentation and other information received from the provider. * Consult with Medical Directors on requests which do not meet clinical criteria and offer alternative covered health care options as appropriate. * Consult Medical Directors on potential quality issues identified during review of medical records. Refer cases to Integrated Health Management, Pharmacy Department or Benefits Integrity Department depending on the concern. * Evaluate suspended claims against medical records to determine the medical necessity and appropriateness of medical services, identify irregularities such as over or under-utilization of services, potential up-coding, over billing, etc. * Communicate timely, accurate information either verbally, electronically or in writing using clinical judgment, knowledge of medical/reimbursement policies and plan benefits to providers, members as well as internal MM staff and other internal departments (Claims Administration, Customer Relations, Provider Contracting, etc.). For denied services, ensure the denial, benefit and appeal language are accurate and consistent with department procedures, accreditation and regulatory guidelines. * Identify and refer members with specific medical and/or behavioral health needs or complex case management and collaborate with medical and behavioral case management staff. Identify and refer quality of care issues and suspected fraud, waste or abuse to the appropriate departments. * Perform pre-screening assessment of incoming pre-certification requests to ensure appropriateness of review. Advises non-clinical staff on clinical and coding questions to ensure correct system processes and entries. * Performs all other miscellaneous responsibilities and duties as assigned or directed. #LI-Hybrid * Associates degree in Nursing. * Current, unrestricted Nursing License in the state of Hawaii as an RN or LPN. * Two years clinical, case management or utilization management related experience. * Knowledge of current standards of care to be followed for a given diagnosis and the normative values of medical tests and procedures. * Strong organizational skills * Good communication skills both verbally and written * Analytical skills * Basic knowledge of Microsoft Office applications. Including but not limited to Word, Excel, and Outlook. * Currently licensed in Hawaii as an RN or LPN * (if applicable upon hire, proof of licensure to be provided by employee or confirmed by Human Resources)

Monitor and analyze regulatory/accreditation/business requirements to invoke recommendations for program and/or policy changes as appropriate for various lines of business. Lead/coordinate activities, which include internal audits, quality assurance control, quality improvement, provider satisfaction and department policies and procedures, to meet and/or maintain regulatory/accreditation/line of business requirements. Serve as a resource to internal and external staff regarding issues relating to administrative policies and procedures, medical policies, and researching and resolving problems. Edit all documentation generated by unit e.g., QIAs, reports, executive summaries, presentation materials, workplans, evaluations, annual plans, policies and procedures, minutes, agendas, provide feedback, and develop/generate monitoring reports/tools. Coordinate/schedule training opportunities and develop/present related reports and various documentation. Coordinate, support and document various department activities to ensure deliverables are completed by due date. Perform other duties (e.g., attend meetings) as assigned. #LI-Hybrid

Sustains strong knowledge of encounter system processes within HMSA and external partners. Coordinates and reconciles data exchange with external entities, monitoring quality. Researches complex claim-member-provider scenarios to determine root cause of data submission errors. Coordinates activities with internal staff to optimize encounter submission processes. Actively participates in the planning, implementation, and testing of projects to increase the scope or efficacy of encounters submission. Analyzes project objectives, data sources, and methodology. Provides data to support financial reporting. Monitors government/vendor requirements changes. Determines and communicates impact. Ensures submission methodologies are compliant with published guidance.

Monitor the performance and address issues with any business partners or vendors that supports the Members Servicing Department. Build relationships with both internal and external customers to include members and employer groups to address issues and concerns and improve the customer experience. Recruit and retain effective teams through selection, development, compensation and motivation of personnel; develop talents necessary to achieve short- and long-term objectives through effective training, mentoring and coaching. Provides feedback and guidance, including timely completion of interim and annual performance reviews. Monitors overall workflow and prioritizes staff's work. Review financial information and adjust operational budgets to promote and demonstrate desired corporate financial stewardship and outcomes. Performs all other miscellaneous responsibilities and duties as assigned or directed. #LI-Hybrid