Manager, Clinical Review

HMSA; Honolulu (HI); On-site; USD 120,000 - 160,000; Full time

Benefits offered by this job

Health insurance

Job summary

HMSA in Hawaii seeks an experienced Senior Manager to lead multiple units across locations, fostering teamwork and staff development.

You will align operations with HMSA strategic initiatives, ensure compliance with HMSA, NCQA and DOL standards for preauthorization and concurrent reviews, and oversee LTSS, CIS and EVV programs.

Collaborate with internal and external partners, mentor staff, manage resources, and drive process improvements.

Responsibilities

• Management of multiple units/teams and staff in multiple locations, fostering a work environment that encourages teamwork, promotes personal growth and learning.
• Provide leadership and direction to align with HMSA strategic initiatives and mission, as well as best practices in the industry.
• Provide leadership, direction and support to the teams to ensure compliance with HMSA, NCQA and DOL standards governing the timeliness and quality of preauthorization activities.
• Oversee compliance with legal and contractual standards related to precertification, payment determinations and concurrent reviews so that cases are reviewed timely and in accordance with HMSA's policies and benefits and accreditation standards.
• Management of the multi-department QUEST Integration programs associated with Long-Term Services Support (LTSS), Community Integration Services (CIS) and Electronic Visit Verification (EVV).
• Serve as a subject matter expert for MM, leading and/or participating in internal committees, workgroups and projects. Such groups may be focused on problem resolution, program updates or implementation of new programs and initiatives that support compliance and/or HMSA goals.
• Oversees and collaborate with internal and external partners in the development and implementation of new or updated programs, workflows, policies & procedures system solutions to support the objectives of the respective team(s).
• Hires, develops, coach and mentor staff to effectively meet corporate and department goals / objectives associated with management of the benefit cost trend through the implementation of utilization management activities.
• Assess, identify and manage the appropriate resources needed to effectively meet HMSA Center business goals (budget, staff, support, coaching, etc.).
• Allocate and re-allocate the appropriate resources based on workload and/or changing business needs.
• Collaborate on a regular basis with departmental management teams to develop, implement and create coordination among all workflows and processes among multiple internal teams.
• Research and resolve, complex and/or high-level member and provider inquiries.
• Perform special projects as assigned.

Job description

1. Management of multiple units/teams and staff in multiple locations, fostering a work environment that encourages teamwork, promotes personal growth and learning.
   • Provide leadership and direction to align with HMSA strategic initiatives and mission, as well as best practices in the industry.
   • Provide leadership, direction and support to the teams to ensure compliance with HMSA, NCQA and DOL standards governing the timeliness and quality of preauthorization activities.
   • Oversee compliance with legal and contractual standards related to precertification, payment determinations and concurrent reviews so that cases are reviewed timely and in accordance with HMSA's policies and benefits and accreditation standards.
2. Management of the multi-department QUEST Integration programs associated with Long-Term Services Support (LTSS), Community Integration Services (CIS) and Electronic Visit Verification (EVV).
3. Serve as a subject matter expert for MM, leading and/or participating in internal committees, workgroups and projects. Such groups may be focused on problem resolution, program updates or implementation of new programs and initiatives that support compliance and/or HMSA goals.
4. Oversees and collaborate with internal and external partners in the development and implementation of new or updated programs, workflows, policies & procedures system solutions to support the objectives of the respective team(s).
5. Hires, develops, coach and mentor staff to effectively meet corporate and department goals / objectives associated with management of the benefit cost trend through the implementation of utilization management activities.
   • Assess, identify and manage the appropriate resources needed to effectively meet HMSA Center business goals (budget, staff, support, coaching, etc.).
   • Allocate and re-allocate the appropriate resources based on workload and/or changing business needs.
6. Collaborate on a regular basis with departmental management teams to develop, implement and create coordination among all workflows and processes among multiple internal teams.
7. Research and resolve, complex and/or high-level member and provider inquiries.
8. Perform special projects as assigned.

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