Healthfirst

Operations

• responsible for the promotion and enablement of a data-driven culture within Healthfirst Operations
• identify opportunities for the use of technology and analytics to improve efficiency within the department and across the organization
• leverage available data to develop preventative and detective controls to ensure timeliness, accuracy, and completeness of business processes
• Contribute to the design and architecture of data models and dashboards used to retain and present key information to the business
• Analyze and reconcile premium revenue and remittance status, accounting for rate changes across all product lines
• Anticipate and solve strategic and high-risk business problems with broad impact on the business area
• Communicate new knowledge and insights gained from analysis of big data

Senior Operations Analyst, Care Management

Product Manager

• Help create and deliver business systems and operational processes
• Interface between the operations team and the delivery of new technology and code
• Prioritize features for development and approve user stories
• Create, refine, and prioritize the Product backlog
• Work daily with scrum teams to refine, groom, and accept stories and bugs for implementation
• Create UAT test cases and facilitate UAT testing
• Represent the team to external stakeholders and leaders
• Support the Agile Program and ensure adherence to enterprise Agile standards
• Identify opportunities for process optimization and redesign
• Communicate effectively with internal stakeholders

Product Owner

Compliance

• The Senior Strategic Data Analyst is responsible for the promotion and enablement of a data-driven culture within Healthfirst Operations.
• Understand the health insurance industry and identify opportunities for the use of technology and analytics to improve efficiency within the department and across the organization.
• Play an integral role in pursuing department initiatives by leveraging analytics to provide insights that support key decisions and successful outcomes.
• Leverage leading analytical tools to generate insights that facilitate key decisions by department Leadership.
• Develop repeatable analytics aimed at department and Executive Leadership that provide insights into the health and performance of the department.
• Leverage available data to develop preventative and detective controls to ensure timeliness, accuracy, and completeness of business processes.
• Contribute to the design and architecture of data models and dashboards used to retain and present key information to the business.
• Identify downstream impacts of changes and enhancements to current analyses, models, and algorithms.
• Assist with the development and execution of highly complex algorithms and statistical predictive models from large sets of data.
• Determine analytical approaches and modeling techniques to evaluate scenarios and potential future outcomes.
• Inference data to make recommendations and decisions.
• Develop repeatable ETL processes from source systems to the analytics sandbox, ensuring integrity, completeness, and accuracy of data is maintained.
• Perform statistical analysis to quantify the limitations of models.
• Develop and improve upon metrics that evaluate department performance.
• Think critically about the business and how the work is performed.
• Identify opportunities to improve the status quo, inject data into the decision-making process, and support progress with facts.
• Serve as a trusted contact for internal department members or other departments.
• Work with the business to define methodologies that directly address their concerns and present results or deliverables to the business.
• Analyze and reconcile premium revenue and remittance status, accounting for rate changes across all product lines.
• Support and report account receivables sub-ledger aging and collections.
• Review, analyze and create detailed documentation reports to support department processes.
• Anticipate and solve strategic and high-risk business problems with broad impact on the business area.

Senior Operations Analyst, Compliance

Full-stack Engineer

• Designs, develops, and maintains complex applications using Pega solutions that adhere to platform best practices
• Develops unit tests and provides code coverage to accurately test business logic and functionality
• Participates in developing specifications including user stories and designs
• Solves and recommends solutions for complex issues and problems
• Assists in the development of logical and physical specifications
• Documents designs, issues, solutions, tips and tricks
• Collaborates within the Agile framework, fostering a team approach to software development and delivery
• Actively engages in improving software delivery through DevOps and other Agile practices
• Stays current in new IT technologies to maintain a high level of subject matter expertise

Pega Tech Lead/Manager

Bilingual

• Manage care plans for patients
• Collaborate with healthcare providers and social services
• Monitor patient progress and adjust care as needed

RN Care Manager, Bilingual Spanish

• Plans and manages behavioral and/or physical care with members
• Advocates, informs, and educates beneficiaries on services
• Develops care plans that align with the physician’s treatment plans
• Liaises between service providers to ensure care is coordinated
• Coordinates with the multi-disciplinary health care team as necessary
• Evaluates service authorizations to ensure alignment of care plans
• Documents all encounters with providers

Care Manager, Bilingual English/Korean

• leads the delivery of provider data management, original claims processing, and claims rework functions
• ensures the successful operation and delivery of Healthfirst claims and provider payment services for federal, state, and commercial programs
• works to increase provider data capabilities, improve accuracy, and ensure compliance while advancing sponsorship model
• provides strategic oversight and leadership to claims-related root cause analysis and determinations
• directs and ensures the efficient and compliant operational management of Claims with emphasis on execution and outcomes
• develops strategic plans to ensure modern and efficient claims management and provider payment

Vice President – Claims and Provider Operations

Manager

• Evaluate members’ care needs and promote quality outcomes and treatment via a variety of modalities and engagement strategies
• Work directly with members in field-based settings and telephonically to support members’ unique care needs and engagement with treatment providers
• Collaborate with hospital clinicians and care management team members (RNs, Social Workers, MDs, Coordinators) to address member needs across the continuum of care
• Provide education and consultation to members, family/caregivers, and other parties involved in the member’s care
• Make community-based field visits, including on-site hospital/facility-based visits around downstate New York
• Apply care management principles by advocating, informing, and educating beneficiaries on services, self-management techniques, and health benefits
• Review discharge planning, assessments, medical records, and screening for members currently admitted to assigned facilities
• Assess need for home care, out of home placement, and/or community-based services and perform Utilization Review as needed
• Develop care plans aligned with the physician’s treatment plans and recommend interventions
• Complete social determinant of health assessments to identify barriers and opportunities for intervention
• Generate referrals to providers, community-based resources, and appropriate services to assist in goal achievement
• Liaise between service providers (doctors, social workers, discharge planners, community providers) to ensure coordinated care
• Coordinate and facilitate with the multidisciplinary health care team to ensure person-centered care plans
• Discuss and execute discharge plans with hospital and HF leadership
• Evaluate treatment alignment with the member’s care and physician treatment plan and identify alternative care options
• Document all encounters in the appropriate system in accordance with internal documentation procedures and update care plans as appropriate
• Occasional overtime and additional duties as assigned

Field Care Manager – Behavioral Health

• Provide telephonic and occasional onsite care management to high-risk, medically frail members
• Engage members, their supports, providers, and health care team members to coordinate care and improve outcomes
• Attend Interdisciplinary Team (IDT) rounds several times per week to discuss high-risk cases
• Conduct assessments to identify barriers and opportunities for intervention and develop care plans aligned with physician treatment plans
• Conduct home visits and field visits to members and local healthcare facilities as needed
• Generate referrals to providers, community-based resources, and appropriate services
• Liaise between service providers (doctors, NPs, social workers, discharge planners, community providers) to ensure coordinated care
• Coordinate and facilitate multi-disciplinary health care team to ensure person-centered treatment and goal achievement
• Evaluate service authorizations for alignment with member care and physician treatment plans
• Document all encounters in appropriate systems and update care plans accordingly
• Contribute to corporate goals through execution of member care plans and member goal achievement

Bilingual Spanish Care Manager

• Coordinates the care plan for assigned members and conducts pre-certification, concurrent review, discharge planning, and case management as assigned
• Responsible for efficient utilization of health services and optimal health outcomes for members
• Provides case management services for assigned member caseloads including pre-certification, risk-identification, preadmission, concurrent and retrospective reviews to evaluate appropriateness and medical necessity
• Assessment: identifying medical, psychological, and social issues that need intervention
• Coordination: partnering with PCP and other medical providers to coordinate treatments, collateral services, and service authorizations
• Negotiates rates with non-partner providers, where applicable
• Ensures appropriate access and utilization of a full continuum of network and community resources
• Documents all determinations, notifications, interventions, and telephone encounters per documentation standards and regulatory guidelines
• Reports and escalates questionable healthcare services
• Meets performance metric requirements and monitors assigned caseload
• Functions as a clinical resource for the multi-disciplinary care team to maximize member care quality while achieving effective medical cost management
• Assists in identifying opportunities for and facilitating alternative care options based on member needs and assessments
• Occasional overtime as necessary
• Additional duties as assigned

UM Case Manager

Customer Support

• Conduct outreaches for newly enrolled members to review current and approved services, DME and additional requests
• Review intake documents for pre-approved services and escalate discrepancies as needed
• Complete Welcome Onboarding and Consumer Directed Personal Assistant Assessments and identify issues or clinical risks for escalation
• Initiate and finalize authorizations in Trucare for preapproved services and DMEs; update and discontinue authorizations when applicable
• Handle and accurately document calls with members regarding benefits, appointments, assessments, service issues, and grievances
• Handle and accurately document calls with providers regarding authorizations, referrals, visits, tests, and faxed care plans
• Provide education to members and providers about approval requirements for service requests
• Manage a large caseload while communicating member issues and monitoring screenings to improve quality and cost outcomes
• Communicate with inter/intra-departments to reconcile onboarding issues
• Handle member mailings, fax clinical requests and approved service plans, and other non-clinical support tasks