Healthfirst

Analyst

• Evaluate the existence, sustainability, and operating effectiveness of internal controls over operations and finance related activities
• Maintain and update internal control / Model Audit Rule documentation
• Assess the design and operating effectiveness of controls
• Support in the design and implementation of internal controls across related business areas
• Lead process walk-throughs with process and control/business owners
• Document and assess internal controls including evaluations, control weaknesses/gaps and reporting results as required
• Monitor remediation of control weaknesses/gaps and provide recommendations for operational/process improvements
• Drive completion of assigned tasks, adhering to deadlines and ensuring compliance to IIA Standards and Principles

Internal Audit Analyst

Compliance

• Promote compliance with regulatory requirements within Healthfirst's Pharmacy and Dental departments
• Monitor incoming regulations from various sources like CMS and DOH
• Share regulatory guidance with the Pharmacy department
• Act as a liaison between Pharmacy and Regulatory Affairs/Legal
• Data analysis of pharmacy and medical claims data
• Support maintenance of the Restricted Recipient Program (RRP)

Senior Regulatory Specialist

Customer Support

• Conduct outreaches for newly enrolled members to review current and approved services, durable medical equipment (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 any issues or risk factors that require clinical escalations to a CM/PCM.
• Initiate and finalize authorization in Trucare for preapproved services and DMEs and update and discontinue authorizations when applicable
• Handle and accurately document calls to and from members to assist with benefit questions/issues, schedule appointments, assessment inquiries, service issues and grievances
• Handle and accurately document calls to and from providers regarding authorizations initiation/updates, referrals, visits, tests, and faxed care plans
• Provide education to members and providers regarding requirements for approval of service requests
• Manage a large caseload while communicating member issues or needs and monitoring screening of members effectively to improve quality and cost outcomes
• Communicate with Inter/Intra-departments regarding reconciling onboarding issues
• Additional duties as assigned

Support Specialist

Product Designer

• Own end-to-end design of HR service processes across key workflows: onboarding, leave of absence, employee relations workflows
• Establish and maintain a governance model for HR processes
• Define and maintain the HR service catalog, including service ownership and service expectations
• Define process performance metrics and monitor trends and performance
• Partner with HR Technology and IT to ensure workflows align with process design
• Lead the development and maintenance of structured process documentation within eGain
• Partner with key HR leaders to support business outcomes.

Senior HR Process & Service Design Manager

Operations

• Analyze provider data workflows to identify inefficiencies, rework, and process gaps.
• Recommend and implement scalable solutions to improve turnaround times and reduce manual effort.
• Perform reconciliation of provider data across systems (e.g. PDM, Atlas, MHS, HRP).
• Identify discrepancies, conduct root-cause analysis, and partner with stakeholders to resolve issues.
• Ensure data integrity, consistency, and alignment across platforms.
• Participate in QA and UAT testing to validate provider data accuracy and system enhancements.
• Analyze provider data trends and develop insights to support informed decision-making.
• Prepare reports and dashboards highlighting risks, performance metrics, and improvement opportunities.
• Develop and maintain job aids, standard operating procedures, and training materials.

PDO Operations Analyst

Director

• Conducting medical necessity reviews in the context of utilization management and appeals
• Assess/review requests for authorization, and claims payment
• Collaborate with Utilization Management and Care Management and medical departments as needed
• Maintain productivity standards
• Complete mandatory Company compliance training

Director of Medical Reviews

QA Engineer

• Responsible for managing system testing of IT applications
• Delivers test planning and execution in line with strategic business objectives
• Provides technical insight, oversight, strategic context, direction, and leadership
• Ensures all strategic and operational projects meet the highest quality
• Aligns Testing Support Services under the Quality Assurance Team for strategic planning
• Builds the testing process and policies along with defining technical solutions
• Ensures that standardized QA methods and procedures are used for testing activities
• Emphasizes cross functional team collaboration, analytical prioritization, and internal testing audits
• Profiles manual test cases for automation test opportunities
• Reviews functional specifications and assists in evaluating test automation approaches
• Generates quality metrics in partnership with Release Management
• Manages escalated issues and provides timely detailed status reports

Technical Quality Assurance Manager

• Develop and implement strategic goals for the oversight and management of the organization's benefit and retirement plans, programs, and policies
• Lead the design and delivery of benefits programs, ensuring alignment with business goals, market practices, and employee needs
• Direct the strategy and administration of employee benefits, recognition, and retirement programs
• Ensure strategic alignment of benefits with organizational goals and compliance with legal requirements
• Monitor industry and regulatory trends; provide insights and recommendations to inform benefit reviews and renewals; use data and insights to shape strategy, evaluate vendors
• Act as a fiduciary leader, in partnership with the Benefits and Retirement Committee
• Oversee and manage health insurance, 401(k), paid time off, SERP, and disability programs
• Conduct research and analysis of benefit programs, monitoring vendor performance and auditing practices
• Serve as the escalation point for vendor issues, manage RFPs, and negotiate contracts
• Manage and work with broker and vendor partners
• Identify opportunities for cost reduction and program delivery improvement
• Monitor costs and utilization, recommend cost containment strategies, and engage with Finance to ensure accurate accounting, accruals, and funding
• Communicate all benefit related information to employees and prepare regular and ad hoc reports for stakeholders
• Collaborate with HR Communications to enhance communication strategies
• Direct the preparation of filings to meet governmental rules and regulations
• Ensure programs comply with ERISA, ACA, HIPAA, COBRA, FMLA, and other pertinent regulations, and oversee internal audit requirements
• Coach and develop a high performing benefits team focused on continuous improvement and employee experience
• Engage in training and development opportunities to enhance expertise in benefits design and analysis
• Lead annual benefits renewals, Open Enrollment, and employee communications
• Use analytics to provide insights on utilization, cost trends, and employee feedback to inform strategy and decision making
• Prepare reports and presentations for leadership and committees on benefit budgets, forecasts, and trend analyses

Director, Benefits

• Conduct quality audits of A&G items including grievances, pre-service appeals, and post service appeals utilizing appropriate sources of information.
• Analyze errors and determine root causes for appropriate classification, trending, and remediation.
• Record/track quality assessment scores and provide feedback to reduce errors and improve processes and performance.
• Review and investigate appeals and grievances requests to ensure all requests are identified, classified, and fully resolved in a compliant manner.
• Present results of investigations to senior staff and prepare written reports concerning investigation activities.
• Identify defects and improve departmental performance by supporting quality, operational efficiency and production goals.
• Assist in the development of departmental policies and procedures.

Appeals and Grievances Quality Assurance Auditor

Human Resources

• Supports the delivery of all HR initiatives and processes.
• Builds a strong business relationship with the internal clients and serves as a key advisor and confidante.
• Facilitates the design and implementation of 'best solutions' that fuel engagement.
• Actively identifies gaps, proposes and implement changes necessary to cover risks and drive performance.
• Influences positive change in people management and designs and maintains the vitality of the business unit.
• Partners with senior business leaders to develop people strategies to meet operational goals.
• Maintains a strong curiosity mindset by continuously learning about the organization, leadership styles, and evolving HR best practices.

HRBP Manager, IT

• Lead Healthfirst’s enterprise workforce analytics capability and strategic workforce planning function
• Transform workforce data into actionable insights that support organizational strategy, financial performance, operational effectiveness, and talent outcomes
• Partner with Human Resources leadership to inform and deliver upon Healthfirst’s talent strategy
• Develop data-driven insights across workforce areas such as hiring, retention, engagement, workforce composition, productivity, and labor cost
• Oversee the development of compelling workforce stories through HR business intelligence and data visualization
• Consult with business partners to identify workforce needs, develop hypotheses and execute related quantitative analyses
• Establish discipline and governance in workforce reporting and analytics