Hawaii Medical Service Association Director, Member Advocacy and Appeals in Honolulu, Hawaii

Company:Hawaii Medical Service Assn.Job Title:Director, Member Advocacy and AppealsExempt or Non-Exempt:ExemptIsland:OahuCity:HonoluluLocation:HonoluluEmployment Type:Full TimeJob Summary:Leads the overall HMSA member advocacy and appeals function to ensure member appeals, complaints and grievances are fully and effectively responded to and completed timely and accurately while delivering the highest level of stakeholder experiences and encouraging member engagement. Responsible for identifying and addressing the root cause (source) of problems, identifying members who may need case management, providers that may need additional assistance and situations which require immediate intervention, referral for utilization management, clinical handling, policy update or special review of grievances or fraud, waste and abuse.Is responsible for the function that handles appeals, complaints and grievances consistently, effectively, and efficiently within the guidelines and time frames required by HMSA policies, government mandates and accreditation requirements. Develops and leads the Member Advocacy and Appeals Department including overall strategy, financial and tactical plans, and policies and procedures. Responsible for all employees within the Department, and is charged with coordinating and providing the necessary training, skills and competency development and mentoring guidance. Responsible for the continual review and revision (when necessary) of the organizational structure, all operational procedures, and implementing any new regulations and laws that affect the appeals function or are related to the appeals function. Leads the department and participates in corporate planning efforts, assuring that the department is aligned by goals and engagement with the corporate strategy and priority items.Duties and Responsibilities:

  • Responsible for overseeing the operations of the Member Advocacy and Appeals (MAA) Department with and through management team. The Department’s responsibilities include the investigation of cases, compliance with the documented process, tracking, reporting, appeal committee reviews, administrative review panel reviews, notifications to members of processes and benefits determinations and appropriate appeals closure. Interacts with corporate decision-makers (i.e., Appeals Committee members, Senior Executives, Executives and Medical Directors) and providers, intercedes on behalf of the member while maintaining the integrity of the health plan contracts..

  • Responsible to direct the development and implementation of the Member Advocacy and Appeals policies and procedures to create an effective and efficient operating environment. 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.

  • Responsible for the development of the MAA Department staff, including timely and relevant performance reviews (PMPs), training, guidance, and career development. Develops performance measurements and communicates the expectations to staff. Responsible for the 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 recommendations and consideration, including any increases upon annual review and bonuses.

  • Translates HMSA’s vision and mission statement with management team into strategic, tactical and operational plans for the MAA Department. Develops and maintains these plans to remain consistent with changes in any legislative mandates and HMSA’s business strategies and priorities.

  • Leading the management team to assess the effectiveness of the Department organizational structure, resources, technology and processes and develops action plans for improvement. 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.

  • Represents the MAA Department on various teams and work groups where appeals are related or affected and responsible for the development of business partnerships. This includes continuous improvement activities with an empowered staff and the departments that are considered the source of appeals and grievances.

  • 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.

  • Assists in special projects and performs other duties as assigned.

Minimum Qualifications:

  • Bachelor’s (BA) degree and five (5) years of related work experience; or equivalent combination of education and work experience.

  • Two (2) years of increasing supervisory experience.

  • One (1) year of experience in corporate or department-level strategic, tactical planning and budgeting.

  • Effective verbal and written communication skills.

  • Demonstrated ability to work independently, managing multiple priorities simultaneously and under strict time constraints.

  • Working knowledge of PC word processing, database and spreadsheet programs.

  • Working knowledge of the operations of managed care programs and government contracts.

  • Work hours determined by business needs and may require periodic evening or weekend work

EEO/AA/Disability/Vets Employer