Medical Management Vendor Relations Analyst

HMSA•Honolulu, HI

13h•Hybrid

About The Position

This role is responsible for coordinating and managing various aspects of utilization management programs delivered by delegated vendors. The analyst ensures that vendor deliverables, documentation, and reporting meet contractual, compliance, and accreditation requirements. This includes developing data templates, maintaining program documentation, analyzing business issues, troubleshooting workflow and complaint issues, and identifying opportunities for process improvement. The position also involves regular interaction with vendors and internal committees, presenting program evaluations and audit reports, and providing guidance and training. A key aspect of the role is ensuring program compliance with standards such as NCQA UM standards and coordinating reporting for state and federal agencies.

Requirements

Bachelor's degree and three years of work experience or equivalent combination of education and experience.
Working knowledge/skills in project management/coordination.
Working knowledge in issues identification, data collection, and validation.
Strong oral and written communication skills with the ability to provide information to management, providers, vendors, and other employees.
Basic working knowledge in Microsoft Office applications, including Word, Excel, and Outlook.
Working knowledge of database and spreadsheet programs.

Responsibilities

Coordinate and manage deliverables of aspects of utilization management programs by delegated vendors, ensuring program deliverables, documentation, and reporting are complete and meet contractual, compliance, and accreditation requirements.
Develop data templates and submission forms, and maintain program documentation for auditing purposes.
Analyze business issues, including new services, contract deliverables, and enhancements.
Troubleshoot workflow issues and member/provider complaints, recommending solutions to management and internal departments.
Review status reports to ensure projects progress on schedule, modifying plans as required, and preparing project reports for management, partners, or others.
Identify and implement opportunities for process improvement in workflows and infrastructure operations, initiating change and evaluating impact.
Present vendors' UM program description, program evaluation, and delegation oversight audit reports to HMSA's cross-functional committees.
Meet regularly with vendor's operational areas to assist with oversight of the vendor program and services.
Provide coordination and guidance to other departments and external resources in managing work to support efficient program operations.
Lead coordination of internal cross-departmental meetings.
Provide training and consultation to vendor staff on an as-needed basis.
Facilitate quarterly UM file reviews with Medical Director's guidance.
Act as a liaison between vendors and HMSA departments for various audit activities.
Coordinate with vendors to ensure timely and accurate reporting of UM decisions as required by state and federal agencies.
Provide subject matter expertise in evaluating vendors' compliance with NCQA UM standards.
Prepare vendors' documentation in consultation with Quality Improvement department for submission to NCQA during re-accreditation surveys.
Perform all other miscellaneous responsibilities and duties as assigned or directed.