Membership Admin Lead — Operations, KPIs & Compliance

hmsacareers

Honolulu (HI)

Hybrid

USD 90,000 - 130,000

Full time

14 days+

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Job summary

HMSA Careers in Hawaii seeks a Membership Admin Leader to guide a team, train staff, and optimize case processing. You will oversee daily operations, resolve escalated cases within SLA, and drive improvements in accuracy and efficiency across underwriting, legal, and servicing teams.

You will maintain audit trails and stay compliant with evolving health plan regulations. The role requires knowledge of managed care plans, claims systems, and strong communication skills, with proficiency in MS

Qualifications

Bachelor's degree and five years of related work experience; or equivalent combination of education and related work experience.
Two years of leadership, supervisory, or management experience.
In-depth knowledge of managed care, PPO, HMO, Medicaid, Medicare Advantage, and commercial group health plans
Working knowledge of claims adjudication systems (e.g., Facets, QNXT, Epic Tapestry, HealthEdge)
Effective written and verbal communication skills
Intermediate working knowledge of Microsoft Office applications including, but not limited to Word, Powerpoint, Outlook and Excel.

Responsibilities

Manage and lead a membership admin team by providing training, mentorship, and best practice solutions.
Manage daily operations of the membership admin team, including inventory analysis, tracking and resolution
Serve as the escalation point for complex or disputed cases and drive resolution within defined SLA.
Monitor and analyze key performance indicators (KPIs) and take corrective actions to improve efficiency, accuracy, and customer satisfaction
Collaborate with key stakeholders to include underwriting, LOB, legal, servicing teams to ensure a consistent and integrated approach to accurate and timely case processing.
Maintain documentation, audit trails, and reporting in line with internal controls and external compliance requirements.
Contribute to the development and implementation of new policies, procedures, and systems to improve membership admin operations.
Stay current with changes in laws, regulations, and industry best practices related to membership admin management. Performs all other miscellaneous responsibilities and duties as assigned or directed.