Director, Payment Integrity at HMSA (Hawaii Medical Service Association)
HMSA (Hawaii Medical Service Association) · Honolulu, United States Of America · Hybrid
- Senior
- Office in Honolulu
- Strategic Leadership:
- Develop and execute the organization's payment integrity strategy, aligning with enterprise cost containment goals.
- Oversee the design and implementation of pre-pay and post-pay review processes.
- Operational Oversight:
- Manage payment integrity programs and functions, including first pass and second pass code editors, data analytics, provider audit, and subrogation.
- Ensure accurate identification and resolution of claim overpayments.
- Collaborate with claims, provider network, compliance, and finance departments to improve payment accuracy.
- Analytics & Reporting:
- Direct the development of analytical models and reporting dashboards to identify patterns of improper payment.
- Monitor key performance indicators (KPIs) such as savings achieved, recovery rates, and audit cycle times.
- Compliance & Governance
- Ensure compliance with CMS, State Medicaid, ERISA, and commercial regulations around claims adjudication and payment practices.
- Partner with Compliance, Legal, and SIU (Special Investigations Unit) to manage regulatory audits and oversight.
- Vendor & Relations:
- Manage relationships with third-party payment integrity vendors, ensuring contract compliance and performance metrics are met.
- Stay current with changes in laws, regulations, and industry best practices related to claims management
- Performs all other miscellaneous responsibilities and duties as assigned or directed.
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