Plan Performance Analyst I

Assists with and/or performs operational quality measures as assigned for limited lines of business and document errors with assistance by:

Applying basic knowledge of HMSA's benefits and their application

Reviewing provider contracts/rates and compare them to "Plan Benefits" to ensure that HMSA's payment or denial agrees with both the provider contract terms and member benefits.

Applying HMSA's medical policies in equating diagnosis to procedures listed on claims

Applying basic knowledge of HMSA's Claims, Customer Service, and Enrollment Systems.

Applying basic knowledge of BCBSA guidelines of audit procedures

Attend meetings with staff/management in multiple departments to observe/support issue resolution during the review. (Note: All errors are submitted to the appropriate management from supervisor to executive staff.)

Assists in explaining exceptions to appropriate management for correction and document management responses. Audience includes supervisors and managers.

Demonstrate ability for critical thinking under guidance or supervision.

Keep abreast of changes to HMSA products by reviewing memos and other documentation distributed to the unit as well as changes in BCBSA Guidelines.

Performs all other miscellaneous responsibilities and duties as assigned or directed