Healthfirst

Clinical Specialist

• Responsible for case development and resolution of clinical cases
• Research issues
• Reference and understand HF’s internal health plans policies and procedures to frame decisions
• Interpret regulations
• Resolve cases and make critical decisions
• Update file documentation such as the file notes and case summary
• Manage all duties within regulatory timeframes
• Communicate effectively to hand-off and pick-up work from colleagues
• Prepare cases for Medical Director Review ensuring that all pertinent information has been obtained

Appeals and Grievances Clinical Specialist – Quality of Care

Agent

• Provides excellent quality customer service to our members and/or providers relating to all aspects of member/provider questions and issues such as eligibility, benefits, claims process, escalations, and product questions, etc.
• May include but is not limited to inbound/outbound calls/emails/chats, onsite/remote/virtual/field location, on behalf of CCO.
• Meets/Exceeds all performance KPIs including but not limited to quality, productivity, and dependability
• Follows established policies and procedures to ensure member and provider issues are addressed timely and accurately
• Identifies and de-escalate situations where member/provider is upset and provides resolution for their issue.

CCO Service Agent

Associate

• Support identifying areas of profitable growth opportunity
• Assist in developing and implementing planned improvements
• Support identifying key cohorts and opportunities for achieving short- and long-term membership growth and retention across product lines
• Work collaboratively with finance analysis, sales, and marketing to develop market growth plans to achieve membership objectives
• Support identifying key opportunities around revenue and medical cost management for profitable growth
• Establish a system to track and quantify program success including target opportunities, success/growth rate and cost of retention
• Collect and monitor competitive intelligence including benefit design and enrollment landscape providing insights and recommendations for future growth
• Coordinate and monitor vendor programs aimed at market growth and retention
• Participate in and assist with ad hoc projects such as member focus groups, annual Go-To-Market product planning, and sales training
• Coordinate with Product Operations teams to pro-actively identify and troubleshoot issues to resolution
• Performs all other necessary and requested product duties.

Managed Care Strategy Associate

Vice President

• Partner with senior leadership to design and implement methods and procedures for claim & benefit configuration
• Provide strategic leadership and oversight to establish plans for accurate claims and provider payment practices
• Ensure configurations match fee schedules and negotiated rates
• Oversee credentialing workflow and compliance
• Develop and improve the Provider Payment experience
• Manage and develop teams through hiring, training, and feedback

AVP, Payment Configuration

IT Support

• Build, lead, and mature the claim configuration quality audit function, including audit planning, methodology, governance, quality standards, reporting, and remediation oversight.
• Develop and maintain a risk-based audit plan that prioritizes claim configuration and reimbursement risks based on volume, dollar exposure, provider type, line of business, regulatory or contractual commitments, recent configuration activity, and known issue patterns.
• Establish claim configuration audit programs, sampling logic, testing protocols, workpaper standards, quality review expectations, issue rating criteria, and documentation requirements.
• Oversee routine, targeted, and risk-based audits and analyses of provider pricing configuration and claims across multiple lines of business, products, and provider types.
• Ensure claim processing outcomes are validated against provider contract terms, fee schedules, reimbursement methodologies, benefit or business rules, and applicable federal and state requirements.
• Review and approve audit scopes, test plans, workpapers, findings, root-cause conclusions, financial impact analyses, and remediation validation results.
• Own or oversee issue logs, corrective action plans, remediation milestones, validation plans, and closure evidence for identified claim configuration and payment defects.
• Monitor remediation effectiveness, recurring issue patterns, and control performance and escalate barriers, delays, or unresolved risks to appropriate leadership.
• Lead the design of an analytics strategy used to detect outliers, trends, variances, root causes, and potential payment defects within claims, provider, contract, and configuration data.
• Oversee the development and maintenance of dashboards, scorecards, recurring reporting, databases, data extracts, and audit samples used to monitor claim payment accuracy and remediation effectiveness.
• Manage, coach, and develop analysts responsible for claim configuration audits, payment validation, data analysis, issue documentation, and remediation tracking; assign work, monitor productivity, and ensure timely completion and consistent quality across all audit activities and deliverables; provide technical guidance, peer review, and feedback to ensure findings are well-supported, consistently documented, and appropriately risk rated.
• Translate complex claim configuration, reimbursement, and data findings into clear business narratives and actionable recommendations for technical and non-technical audiences.
• Present audit results, quality trends, risk ratings, financial exposure, corrective action status, and recommendations to leadership and cross-functional workgroups, governance meetings, and forums.
• Continuously evaluate audit coverage, control gaps, and emerging risks and adjust priorities to support organizational objectives and regulatory or contractual requirements.
• Provide subject matter expertise on provider contract reimbursement language, claims adjudication logic, configuration controls, and expected system outcomes.
• Recommend and influence process, control, system, training, and workflow improvements to strengthen configuration accuracy and prevent recurring defects.
• Build effective working relationships with business, technical, finance, compliance, contracting, and leadership stakeholders to support issue resolution and control improvement.
• Partner with IT, Analytics, Finance, and operational leaders to improve data access, automate recurring analyses, strengthen reporting reliability, and support scalable monitoring.
• Promote a culture of accountability, documentation discipline, quality, and continuous improvement across the audit function and partner teams.
• Create and maintain policies, procedures, audit playbooks, training materials, and standard work products for the function.
• Perform other projects and duties as assigned.

Configuration and Quality Audit Manager

Customer Support

• Manages designated caseload of members who could benefit from Peer Support services
• Schedules and conducts multiple field-based visits per day
• Completes assessments and questionnaires to identify barriers and opportunities for intervention
• Works telephonically when not in the field
• Generates referrals to providers, community-based resources, and appropriate services
• Liaise between service providers to ensure care is coordinated
• Collaborate as part of the multi-disciplinary health care team to ensure care needs are addressed

Peer Support Specialist

Data Engineer

• Finds trends in datasets and develops workflows and algorithms to make raw data useful to the enterprise
• Designs and implements standardized data management procedures around data staging, data ingestion, data preparation, data provisioning, and data destruction (scripts, programs, automation, assisted by automation, etc.)
• Ensures quality of technical solutions as data moves across Healthfirst environments
• Provides insight into the changing data environment, data processing, data storage and utilization requirements for the company and offers suggestions for solutions
• Ensures managed analytic assets support Healthfirst’s strategic goals by creating and verifying data acquisition requirements and strategy
• Develops, constructs, tests and maintains architectures
• Aligns architecture with business requirements and uses programming language and tools
• Identifies ways to improve data reliability, efficiency, and quality
• Conducts research for industry and business questions
• Deploys sophisticated analytics programs, machine learning and statistical methods
• Prepares data for predictive and prescriptive modeling and finds hidden patterns using data
• Uses data to discover tasks that can be automated
• Creates data monitoring capabilities for each business process and works with data consumers on updates
• Aligns data architecture to Healthfirst solution architecture; contributes to overall solution architecture
• Helps maintain the integrity and security of the company data

Healthcare Claims, Data Engineer

Data Analyst

• Analyze complex healthcare datasets to identify trends, anomalies, control gaps, and potential compliance or operational risks.
• Support Internal Audit, Compliance, and Claims Configuration Audit activities through data analysis, audit testing, monitoring, and reporting.
• Develop advanced SQL, SAS, or other analytical queries to extract, validate, and analyze data from multiple sources.
• Evaluate data quality and standardize data structures to support consistent reporting and analysis.
• Create and maintain dashboards, scorecards, reports, and monitoring tools that provide actionable insights to leadership and business stakeholders.
• Summarize findings, methodologies, and recommendations for technical and non-technical audiences.
• Assist in the validation of claims configuration changes, business rules, and operational controls.
• Document analytical processes, data issues, methodologies, and business requirements.
• Collaborate with Internal Audit, Compliance, Claims Operations, Configuration, IT, and other business partners.
• Demonstrate intellectual curiosity and identify opportunities for process, control, and reporting improvements.

Senior Analyst, Audit and Compliance Analytics

Spanish

• Conducts home assessments (and virtual assessments, as needed) 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 and critical thinking skills.
• As needed, conducts assessments in settings other than home as needed, e.g. skilled nursing facilities or virtually
• Navigates multiple technology/digital platforms such as UAS software, electronic medical records, TruCare, etc., to conduct and document comprehensive assessments accurately and efficiently
• Completes assessment of service needs per CMT and member's family/caregiver’s request to determine service needs or any necessary adjustments
• Reviews previous nursing assessments/medical notes to determine necessary adjustments/updates in Care Plan and/or to assist with nursing home admission
• Conducts in-person Care Management visits in support of person-centered service planning
• Liaisons between the member and the CMT; assesses home environment and psychosocial status
• Provides feedback to home care agencies and CMT regarding home care issues and contract nurses and aides performance
• Provides grass roots, community-based training for frail population care including self-care techniques and prevention strategies
• Ensures (prospective) members and significant others/responsible parties understand and are in agreement with enrollment in a managed long-term care plan
• Additional duties as assigned

Registered Nurse, Bronx, NY

Care Coordinator

• Receive incoming calls from members regarding benefit questions/issues, care coordination, program inquiries, connecting to their care manager, and screening assessments to identify risk factors requiring medical intervention
• Contemporaneously and accurately documents calls in designated PHI system
• Manages an assigned member caseload who require short term care coordination and health navigation
• Works within the interdisciplinary care team to support timely communication of member issues or needs and monitors screening of members effectively to improve quality and cost outcomes
• Performs outreach calls to members to confirm services are in place
• Additional duties as assigned

• Receiving, investigating and responding verbally and in writing to member and provider clinical appeals and grievances
• Ensures that appeals and grievances are properly classified (e.g. denial of service, denial of payment, or a grievance about a provider)
• Processes appeals and grievances in accordance with internal company policy
• Enters data into appropriate medical management services
• Collaborates with other departments to thoroughly investigate appeal and grievances
• Prepares for and participates in regulatory site visits
• Additional duties as assigned

Appeals & Grievances Clinical Specialist

Systems Engineer

• Elicit, document, and analyze business and functional requirements for operational workflows, system enhancements, and process improvements
• Configure, maintain, and support operational systems, applications, and workflow tools
• Translate business requirements into technical specifications and functional system configurations
• Partner with operational stakeholders to identify automation opportunities and streamline manual processes
• Troubleshoot system issues, perform root cause analysis, and implement sustainable solutions
• Support testing activities including test scenario creation, user acceptance testing, and validation of system enhancements
• Create and maintain process documentation, system documentation, training materials, and standard operating procedures
• Monitor application performance and recommend enhancements to improve usability, scalability, and operational effectiveness
• Support data management, reporting, and dashboard development to provide operational insights and metrics
• Manage ongoing operational support requests and prioritize enhancements within established timelines
• Ensure solutions align with organizational governance, security, and compliance standards
• Act as a subject matter expert for operational systems and business process workflows

Senior Operations Systems Analyst

General

• Good health doesn’t start in a doctor’s office.
• The company’s mission is to put its members first by working closely with care providers and community leaders to address broader issues that can impact health and well-being.

Team Lead Support Coordinator

Product Manager

• Help create and deliver a best-in-class business systems and operational processes
• Be dedicated to the Agile Work Team to interface between the operations team and the delivery of new technology and code
• Be constantly thinking through the processes and needs of the business to support an efficient and error free process for the member and provider
• Represent the business team in prioritizing the features for development, approving user stories, and ensuring clear communication flows back and forth
• Help shape and execute the product strategy that meets the department goals
• Engage in business case development, and ensure adherence to the Agile Scrum process
• Define & communicate the overall vision, objectives and goals of the business.
• Articulate the minimum viable product needs
• Create, refine, socialize and prioritize the Product backlog
• Enable delivery of Product Backlog by presenting backlog to team; creating, owning and refining well-formed user stories and artifacts that describe and detail new products, features and services based on feedback from team, creating acceptance criteria with the team, and accepting stories as they’re completed
• Contribute to the maturity, performance and growth of the Agile team
• Work daily with scrum teams to refine, groom, and accept stories and bugs for implementation
• Create UAT test cases, organize and facilitate UAT testing, track test results, and work with the scrum master and agile team to resolve issues
• Represents the team, when needed, to external stakeholders, leaders and other teams to ensure alignment and understanding progress of the team
• Support the Agile Program and ensure the team follows enterprise Agile standards
• Provide feedback to program on enhancements for the Agile process.
• Champions change and effectively manages the implementation of new ideas
• Ability to align and motivate a team to achieve objectives
• Identify opportunities for process optimization and redesign that will allow us to accomplish objectives more quickly and at a higher level of probability
• Work one on one with each team member to ensure their growth and accountability to the team is achieved.
• Effectively communicates relevant information to all levels of the organization
• Partner with cross-functional teams to build, prioritize and define workflows and requirements
• Reinforces team approach throughout organization both on client projects and internal initiatives
• Supports and solicits input from team members at all levels within the organization
• Create dynamic and a spirit of teamwork and collaboration
• Compliment the broader team with high quality and partnership
• Communicates effectively with internal stakeholders to identify needs and evaluate alternative business solutions and strategies
• Continually defines ways to increase customer satisfaction and deepen business relationships
• All other related and/or additional responsibilities that may be required or assigned

Product Owner – Enrollment and Billing Correspondence

Call Center Representative

• Analyze, manage and delegate daily workflow to and from external vendors
• Analyze and ensure vendor accuracy by reviewing and consolidating work product
• Communicate regularly with department leaders, subject matter experts, and quality teams
• Ensure adherence of regulatory and compliance mandates
• Work with Information Technology to define business requirements
• Administer daily oversight and resolution of issues affecting vendor user system access
• Participate as a liaison between department leaders and vendors
• Maintain accurate documentation of assigned and completed vendor work
• Identify new opportunities for vendor engagement