The Role
Responsible for analyzing and resolving complex member and provider appeals and inquiries while ensuring compliance with policies, regulations, and accreditation standards. Works as a liaison to negotiate sensitive issues and identifies areas for improvement in processes. Assists in quality assurance and communicates trends and needs to management.
Summary Generated by Built In
Job Summary & ResponsibilitiesPreferred Qualifications
- Conducts critical analysis of highly complex and sensitive member and provider appeals, inquiries and grievances and applies internal policies and procedures, contractual provisions, and regulatory requirements.
- Secures information from internal and external resources to resolve issues.
- Assists Supervisor and Coordinator in working as a liaison with providers, members and internal decision makers in representing HMSA objectives, goals, and expectations for meeting contractual, regulatory, and accreditation requirements.
- Negotiates/resolves sensitive issues with internal and external parties.
- Takes all facts and research from internal and external resources and presents a full explanation of the member's or provider's position and concerns to management and decision makers.
- Triages cases to resolve them upon initial inquiry to best service the member as well as minimize the number of cases escalated to senior management and executives.
- At the direction and supervision of management, participates on cross departmental committees and other internal meetings to identify, clarify, research, and resolve inquiries and issues.
- Identifies when changes to policies and procedures are needed based on case resolutions, statutory or regulatory changes, or accreditation requirements.
- Proposes changes to management based on identification and analysis.
- Analyzes and identifies issues that may require multiple department efforts to resolve.
- Presents recommendations to internal committees, subgroups and executive management for decision making purposes as it relates to cases after discussion and approval from Supervisor and Coordinator.
- Assists with the implementation of resulting decisions for change/resolution.
- Assists supervisor/manager in responding to internal investigations, reviews, and audits; regulatory inquiries; and accreditation related audits.
- Assist internal customers with complex member/physician inquiries with guidance and direction from management.
- Identifies member problems, member education needs, or trends and report these to manager, as well as recommend resolution. Takes a proactive role in reviewing, digesting and communicating any new regulation, standard, business change, etc. affecting the member advocacy and/or appeals process. At direction of management, assists in the coordination of changes among departments.
- Performs quality assurance of case documents and assists Supervisor and Manager with various corporate activities.
- Performs all other miscellaneous responsibilities and duties as assigned or directed.
#LI-Hybrid
- Bachelor's degree and one year of related work experience; or equivalent combination of education and related work experience.
- Effective verbal and written communication skills
- Problem identification and resolution skills
- Basic knowledge of Microsoft Office applications. Including but not limited to Word, Excel, Outlook, and Power Point.
Skills Required
- Bachelor's degree and one year of related work experience
- Effective verbal and written communication skills
- Problem identification and resolution skills
- Basic knowledge of Microsoft Office applications including Word, Excel, Outlook, and Power Point
HMSA Compensation & Benefits Highlights
The following summarizes recurring compensation and benefits themes identified from responses generated by popular LLMs to common candidate questions about HMSA and has not been reviewed or approved by HMSA.
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Healthcare Strength — Medical and dental coverage are described as solid, with preventive services and select zero‑cost features adding value in recent plan years. Employer-sponsored plans can have affordable premiums in certain groups and broad access options.
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Retirement Support — A 401(k) with company match and potential discretionary contributions forms a strong component of total rewards. Retirement support complements the core medical and dental package.
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Leave & Time Off Breadth — Paid holidays and PTO that increases with tenure provide meaningful time‑off flexibility. Time‑away benefits scale with service length.
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The Company
What We Do
The Hawaii Medical Service Association (HMSA), an independent licensee of the Blue Cross and Blue Shield Association, is a reliable name in Hawaii health care. Established in 1938, we are the largest and most experienced provider of health care coverage in the state. Over half of Hawaii’s population have chosen HMSA for their health care coverage. We are dedicated to providing quality, affordable health plans; employee benefit services; and worksite wellness programs. HMSA also offers a variety of programs, services and support to help improve the health and well-being of our members and community.
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