The Role
Monitors and improves Federal Employee Program healthcare operations, including utilization, case, medical, and disease management. Coordinates cross-functional teams, analyzes operational data, supports claims and customer service improvements, documents workflows, and reports performance. Assists with compliance audits, regulatory adherence, and fraud, waste, and abuse investigations. Requires travel to training programs, meetings, and conferences and supports daily business operations.
Summary Generated by Built In
Job Summary & Responsibilities
- Monitor, evaluate, educate, and implement FEP program requirements related to Utilization Management (UM), Case Management (CM), Medical Management (MM), and Disease Management (DM) activities to areas within the department for appropriate action. This includes tracking daily operations to ensure deliverables are met and reporting information to FEP Director's Office, various internal committees and other audiences as needed.
- Coordinate cross functional teams (including but not limited to HMSA staff and external partners and providers) to collect, communicate and distribute information and conduct quantitative/qualitative analysis to identify areas of opportunity and make recommendations for department/corporate action to support FEP Plan Incentive Program (PIP) metrics and Mahie 2020 strategic goals.
- Develop methods to improve daily customer service and claims processing operations and practice standards. This includes, but is not limited to, analyzing business problems, enhancements to add functionality and/or redesign of systems to improve efficiencies and documenting policies and procedures, desktop procedures and workflows to monitor, trend and reflect impact of activities.
- Support day-to-day business operations and functions by compiling and reporting on daily activities. This includes identifying trends in operational efficiencies, researching inquiry escalations, responding to secured messages, and administrative tasks.
- Support compliance reviews and audits to monitor adherence with federal and state regulations, FEPDO program rules, Office of Personnel Management (OPM) regulatory guidance, and internal policies and procedures. Ensure that "best practices" are implemented, and observations/findings are satisfactorily resolved.
- Identify and protect FEP assets through a detailed analysis, review, and evaluation of Fraud, Waste, and Abuse (FWA) methodology and best practices consistent with HMSA's FWA program. This includes taking a proactive role in identifying, digesting, and communicating trends and assisting in the coordination of resolution for these trends.
- Performs all other miscellaneous responsibilities and duties as assigned or directed
- Travel to Association-sponsored Plan training programs, meetings, and conferences to understand the current FEP landscape, industry developments, policy or regulatory changes, transformative technologies, operational processes, field service strategies, and other implementing an overall effective FEP program.
#LI-Hybrid
Preferred Qualifications- Bachelor's degree and three years of related work experience; or equivalent combination of education and related work experience.
- Basic working knowledge of Microsoft Office applications. Including but not limited to Word, Excel, PowerPoint, and Outlook.
- Must have valid driver's license, access to an automobile with current license, registration, and no-fault insurance.
- Requires safely operating an insured automobile for travel to off-site locations to conduct and accomplish business related activities.
Skills Required
- Bachelor’s degree and three years of related work experience, or an equivalent combination of education and related work experience
- Basic working knowledge of Microsoft Office applications, including Word, Excel, PowerPoint, and Outlook
- Valid driver’s license
- Access to an automobile with current license, registration, and no-fault insurance
- Ability to safely operate an insured automobile for business-related travel to off-site locations
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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