Medical Management Vendor Relations Analyst

Responsibilities

• Coordinate and manage deliverables of aspects of utilization management programs by delegated vendors:
  • Ensures that program deliverables, documentation, and reporting are complete and meet contractual, compliance, and accreditation requirements.
  • Develops data templates and submission forms.
  • Maintains program documentation for auditing purposes.
• Analyzes business issues, including but not limited to new services, contract deliverables, enhancements, etc.
• Troubleshoots workflow issues as well as member/provider complaints and recommends solutions to management and internal departments.
• Reviews status reports to ensure projects progress on schedule within prescribed guidelines, modifies plans as required, and prepares project reports for management, partners, or others as needed.
• Identifies and implements opportunities for process improvement in workflows and infrastructure operations. Initiates change and evaluates impact.
• Program interaction/Committee involvement:
  • Presents vendors' UM program description, program evaluation, and delegation oversight audit reports to HMSA's cross‑functional committees.
  • Meets regularly with vendor's operational areas to assist with oversight of the vendor program and services.
  • Provides coordination and guidance to other departments and external resources to support efficient program operations.
  • Leads coordination of internal cross‑departmental meetings.
  • Provides training and consultation to vendor staff on an as‑needed basis.
• Subject matter expertise on program compliance:
  • Facilitates quarterly UM file reviews with Medical Director's guidance.
  • Acts as a liaison between vendors and HMSA departments for various audit activities.
  • Coordinates with vendors to ensure timely and accurate reporting of UM decisions as required by state and federal agencies.
  • Provides subject matter expertise in evaluating vendors' compliance with NCQA UM standards.
  • Prepares vendors' documentation in consultation with the Quality Improvement department for submission to NCQA during re‑accreditation surveys.
• Performs all other miscellaneous responsibilities and duties as assigned or directed.

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