Position Summary. The Appeals & Grievances (A&G) unit manages Healthfirst member complaints, grievances and appeals that are presented by the member or provider pertaining to the authorization of or delivery of clinical and non-clinical services. A&G works in collaboration with divisions within and outside the organization to resolve issues in a timely and compliant manner. The A&G Clinical Specialist is the subject matter expert responsible for ...
The Billing Operations Analyst is responsible for generating all State premium revenue across all product lines. The individual will be responsible for ensuring operational effectiveness, coordinating completion and submission to the New York State Department of Health with the IT department for State revenue and ensure all supporting revenue & remittance data has been loaded to the data warehouse for reconciliation and recording. Duties and Resp...
The UM Pharmacy Technician is responsible for the intake and review of prior authorization requests for medications requested under the medical benefit. The UM Pharmacy Technician makes approval decisions and denial recommendations based on predetermined clinical criteria. They establish rapport with Provider offices and leverages strong communication and customer service skills when providing updates and delivering decision notifications to memb...
Summary. The Learning Delivery Specialist will act as an ambassador in fostering the HF culture and supporting the implementation and delivery of content relevant to enterprise initiatives, business units and strategy. This individual will lead and support learning projects and will be responsible for researching, designing, developing, updating, and facilitating classroom and virtual delivery learning events, while partnering with subject matter...
The Claims Implementation Analyst is responsible for assisting in analyzing, implementing and reporting of required claims configuration business rules. The Implementation Analyst will assist management by developing and maintaining reporting tool and processes, querying and analyzing data, identifying root causes, recommending and supporting decision making. The Implementation Analyst owns project goals by developing project plans, establishing ...
The Enrollment Medicaid Specialists provides Healthfirst’ s Medicare Advantage Plan (MAP), Senior Health Partners' (SHP) Managed Long|Term Care (MLTCP), FIDA and Nursing Home members and families with assessment and interventions related to enrollment processing of qualified, eligible candidates for enrollment and obtaining and retaining of financial entitlements for which they are eligible. This enables members to maintain the highest level of i...
The Senior Manager, Marketing Implementation (Technical Project Management) will lead the Marketing Strategy team's implementation operations and project management capabilities. The ideal candidate will work closely with the Marketing Strategy team (Marketing Analytics, Media and SEO) and collaborate with technical stakeholders to ensure seamless execution of projects and campaigns. This highly visible position will be responsible for driving op...
The Complete Care Specialist is responsible for developing and maintaining relationships, leads, and new business using consultative selling/marketing. This role serves as the key player in educating Medicare Advantage and Medicaid Advantage Plus (MAP) benefits to potential members in a manner that is compliant with Centers for Medicare & Medicaid Services (CMS) and Healthfirst’s policies. The Complete Care Specialist is a pivotal presence in the...
This position is Hybrid FL or Hybrid NY. Position Summary. The Team Lead of Workforce Effectiveness at Healthfirst is responsible for overseeing a comprehensive range of functions within the team, including but not limited to Time and Attendance, Planning, Scheduling, and Mission Control for Real-time Analytics. This pivotal role ensures operational excellence and adherence to Service Level Agreements (SLA) across Contact Center Operations and ot...
The Assessment Nurse makes field assessment visits for members or prospective members around downstate New York at intervals required by the Department of Health (DOH) and completes appropriate documentation to determine members’ enrollment, service needs, and continued plan eligibility. This position coordinates with Care Management Team (CMT) to maintain efficient and effective operations of Healthfirst’s long term care plans such as CompleteCa...
The Sr Cyber Security Engineer continuously monitors the vulnerability of the enterprise and develops engineering solutions to improve the security of the Healthfirst infrastructure. The Sr Cyber Security Engineer applies expertise across the Cyber Security discipline by demonstrating competency in IT Infrastructure and Application Development. The individual filling the Governance Risk and Compliance (GRC) Senior Cyber Security Engineer role wil...
The Complex Care, Care Manager plans and manages behavioral and/or physical care for high-risk, medically frail members and works collaboratively with them, their supports, providers, and health care team members. The Care Manager is responsible for engaging members and addressing coordination of their health care services to provide an excellent member experience, address barriers, and improve their health outcomes. The Care Manager works as a c...
