Healthfirst

Claims and Provider Payment Modernization Manager - PayDoc

NY  |  Req ID: R019439

Duties & Responsibilities:Manages assigned initiatives, including workplan development, stakeholder management, change management, implementation, success measurement, and communication of project status to business stakeholders.Partners with IT and Delivery teams in the delivery of technical...

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Communications Manager, PayDoc

NY  |  Req ID: R019444

Develops and implements comprehensive internal communication plans aligned with strategic prioritiesDesigns and presents content to effectively communicate key messages to varying audiences across the organization, including Executive presentations, team town halls, corporate emails, intranet...

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Team Lead Workforce Effectiveness

FL  |  Req ID: R019460  |  Hybrid

Duties and Responsibilities: Provide leadership across all units of the Workforce Effectiveness team, including but not limited to time and attendance, planning, scheduling, and real-time analyticsDevelop, implement, and/or assist in strategies for accurate demand forecasting, ensuring alignment...

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Sr. Workforce Effectiveness Data Analyst

FL  |  Req ID: R019463  |  Remote

Leverage leading analytical tools to generate insights that facilitate key decisions by department LeadershipDevelop repeatable analytics aimed at department and Executive Leadership that provide insights into the health and performance of the department.Leverage available data to develop...

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Clinical Auditor: Appeals and Grievances

NY  |  Req ID: R019368  |  Remote

Duties and Responsibilities:Maintains tracking tools to log audit results including areas of non-compliance and informing what areas of improvement are needed for discussion with management and/or at departmental team meetingsAssists with evaluating and analyzing aggregate quality performance...

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Sr Program Manager, Claims Modernization Product Management

NY  |  Req ID: R019572  |  Hybrid

Duties & Responsibilities:Manages portfolio of initiatives, including workplan development, stakeholder management, change management, implementation, success measurement, and communication of project status to business stakeholders.Partners with IT and Delivery teams in the delivery of...

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Sr Mulesoft Application Developer

NY  |  Req ID: R019586  |  Remote

Duties & Responsibilities:Collaborates within the Agile framework, fosters a team approach to software development (review code) and delivery (release activities and postproduction validations)Apply API-led connectivity concepts to business initiatives to help program achieve their...

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Payment Policy Analyst -100% Remote

NY  |  Req ID: R019581  |  Remote

Duties & Responsibilities:Facilitate the Healthfirst reimbursement and billing guidelines policy process, including developing new policies, monitoring industry reimbursement policy trends, and tracking annual renewalsConduct industry/market research on New York Medicaid and CMS reimbursement...

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Remote UM Pharmacy Technician

NY  |  Req ID: R019592  |  Remote

Duties & Responsibilities:Reviews prior authorization requests and units for medications requested under the medical benefitAssesses provider-submitted clinical information for clinical appropriateness based on predetermined clinical criteriaSends notification to members and providers of...

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Appeals and Grievances Clinical Specialist - RN or LPN - 100% Remote

NY  |  Req ID: R019565  |  Remote

Duties and Responsibilities:Responsible for case development and resolution of clinical cases, such as: Pre-existing Conditions, Prior Approval, Medical Necessity, Pre-certification, Continued Stay, Reduction, Termination, and Suspension of services. The end to end process requires the Specialist...

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Complex Care Care Manager-High Risk Diabetes (Remote)

NY  |  Req ID: R019418  |  Remote

Duties/Responsibilities:Advocates, informs, and educates beneficiaries on services, self-management techniques, and health benefits.Conducts assessments to identify barriers and opportunities for intervention.Develops care plans that align with the physician’s treatment plans and recommends...

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Episodic Utilization Case Manager - 100% Remote

NY  |  Req ID: R019449  |  Remote

Duties/Responsibilities:Provides case management services for assigned member caseloads which includes:Pre-certification – performing risk-identification, preadmission, concurrent, and retrospective reviews to evaluate the appropriateness and medical necessity of treatments and service...

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Per Diem, Assessment RN, Bronx, NY

NY  |  Req ID: R018401  |  Hybrid

Duties and Responsibilities: ·        Conducts home assessments for prospective members and re-assessments of current members using the Uniform Assessment System (UAS); make enrollment and continued eligibility determinations by utilizing clinical expertise...

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Clinical Quality Manager

NY  |  Req ID: R018887  |  Hybrid

Job Description- Interacts with hospitals, providers, and members to improve quality of care, monitor progress, and recommend changes- Reviews billing codes, medical records, and claims submission process to ensure accuracy- Attends and facilitates any initiative meetings (studies, partnerships)...

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Manager, Enrollment & Billing

NY  |  Req ID: R018961  |  Hybrid

•Implements and communicates departmental standards•Manages employee performance and the quality of the team's work•Monitors productivity reports and department report card•Manages and develops Team Leads to be effective leaders•Works with Team Leads to establish and implement departmental goals,...

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Director, Reimbursement Configuration

NY  |  Req ID: R019088  |  Hybrid

Job DescriptionDuties & Responsibilities:Drive flexible, repeatable and scalable claims configuration design and implementation processes with industry best-practicesEngage directly with other operational teams and leaders to provide input on the scope, approach, and timing of configuration...

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Care Manager - Interdisciplinary Team - Hybrid - $3,000 Sign On Bonus

NY  |  Req ID: R019036  |  Hybrid

Duties and Responsibilities:Provides telephonic (and occasional onsite) care management to support the member’s care needs to promote positive health outcomes.Advocates, informs, and educates beneficiaries on services, self-management techniques, and health benefits.Attends Interdisciplinary Team...

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Care Manager - Long Term Care 100% Remote

NY  |  Req ID: R019227  |  Remote

Duties and Responsibilities:Advocates, informs, and educates beneficiaries on services, self-management techniques, and health benefits.Conducts assessments to identify barriers and opportunities for intervention.Develops care plans that align with the physician’s treatment plans and recommends...

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Team Lead Operations • Enrollment & Billing

FL  |  Req ID: R019026  |  Hybrid

**This position is Hybrid NY or Hybrid FLDuties & Responsibilities:Provide day-to-day supervisory leadership to Analytics TeamManage the teams’ progress on various report requests, projects, and testing to ensure quality and deadlines are met  Provide continuous coaching and training to...

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Manager, Clinical Pharmacist UM

NY  |  Req ID: R019219  |  Hybrid

Job DescriptionDuties and Responsibilities: Responsible for developing clinical criteria, medical policies for provider administered medications, review of monthly reports for quality assurance, and staying current with literature, evidence-based medicine, and trends in medicine.Work with...

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