Healthfirst

Role Description Care Coordinators are responsible for performing care management services in order to support members who require assistance in navigating their health care system. The Care Coordinator supports various teams to provide excellent customer service to our NorthStar Members. - 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. Qualifications - Certified Medical Assistant (CMA) or Certified Nursing Assistant (CNA) or Registered Medical Assistant (RMA) or previous relevant medical training or work experience. - HS diploma/GED. - Work experience requiring effective communication verbally and in writing while demonstrating good grammar, spelling, and punctuation skills. - Experience working in a fast-paced environment that requires handling multiple priorities simultaneously. Preferred Qualifications - Associate’s Degree. - Prior work experience in a call center, care management, or healthcare environment or familiarity with medical terminology, Medicaid & Child health plus benefit products. - Excellent telephone, organizational, and customer service skills. - Team player who is organized and detail-oriented. Benefits - Medical, dental, and vision coverage. - Incentive and recognition programs. - Life insurance. - 401k contributions (all benefits are subject to eligibility requirements). Hiring Range - Greater New York City Area (NY, NJ, CT residents): $48,600 - $65,960. - All Other Locations (within approved locations): $42,200 - $62,400.

Role Description The Grievance Specialist is a member of the Appeals & Grievances (A&G) team at Healthfirst and is responsible for managing and resolving member or authorized representative–initiated grievances and complaints across Healthfirst’s product lines, including: - Medicare - Medicaid - Child Health Plus (CHPlus) - Senior Health Partners (SHP) - Commercial Qualified Health Plans (QHP) - Essential Plans (EP) - CompleteCare This is a non-clinical role focused exclusively on grievance and complaint resolution. The Specialist plays a key role in advocating for Healthfirst members by thoroughly investigating their concerns and ensuring timely, accurate, and compliant resolutions in accordance with regulatory requirements. Key Responsibilities: - Independently manage a caseload of grievances through the full case lifecycle, from written acknowledgement to investigation, resolution, and written member resolution letters. - Conduct detailed research by collaborating cross-functionally with internal departments (e.g., Member Services, Provider Operations, Clinical, Enrollment, Pharmacy) to identify root causes and recommend appropriate resolutions. - Partner with external vendors (e.g., DentaQuest, EyeMed, Logisticare vendors) to ensure member issues involving subcontracted services and ancillary benefits are appropriately addressed and resolved. - Draft and issue acknowledgement and resolution letters that are clear, and compliant with regulatory standards and timelines (e.g., NYS DOH, CMS, Medicaid Managed Care Model Contract). - Ensure timely and accurate case documentation in accordance with Healthfirst policies, regulatory requirements, and audit standards. - Participate in department meetings, quality audits, training sessions, in-person quarterly town halls and performance reviews as needed. - Meet department metrics for production and quality. Qualifications - HS Diploma or GED from an accredited institution. - Understanding of utilization management processes and how service authorizations impact member access to care and claims payment. - Proficient in Microsoft Office Suite, including Excel (sort, track and filter trends), Word, PowerPoint, Outlook and case tracking systems. Requirements - Bachelor’s degree or equivalent experience in healthcare, public health, or a related field preferred. - 2+ years of experience in managed care, member services, or healthcare grievances or complaints resolution. - Working knowledge of Medicare Advantage, Medicaid Managed Care, Child Health Plus, Essential Plans, and/or Health Insurance Exchange (Marketplace/QHP) programs. - Familiarity with applicable state and federal regulatory requirements, such as CMS regulations, the NYS Department of Health (DOH) Medicaid Managed Care Model Contract, and the Department of Financial Services (DFS). - Experience with or knowledge of claims processing and provider billing workflows. - Exposure to or direct experience with long-term services and supports (LTSS), including Personal Care Services (PCS) and Consumer Directed Personal Assistance Services (CDPAS). Benefits - Medical, dental and vision coverage - Incentive and recognition programs - Life insurance - 401k contributions (all benefits are subject to eligibility requirements) Company Description WE ARE AN EQUAL OPPORTUNITY EMPLOYER. HF Management Services, LLC complies with all applicable laws and regulations. Applicants and employees are considered for positions and are evaluated without regard to race, color, creed, religion, sex, national origin, sexual orientation, pregnancy, age, disability, genetic information, domestic violence victim status, gender and/or gender identity or expression, military status, veteran status, citizenship or immigration status, height and weight, familial status, marital status, or unemployment status, as well as any other legally protected basis. If you have a disability under the Americans with Disability Act or a similar law and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to careers@Healthfirst.org or calling 212-519-1798. In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within HF Management Services, LLC will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with HF Management Services, LLC.

Role Description The Pharmacy Technician is responsible for providing member medication counseling and assistance in minimizing gaps in treatment by collaborating with various members of the healthcare team within Healthfirst and with our community partners (pharmacists and providers). Duties & Responsibilities: - Performs review of medication lists to understand and eliminate barriers to medication therapy while serving as the member's Pharmacy Navigator in order to achieve the following: - Proper Medication Adherence - Minimize any gaps in therapy - Prevention of medication related adverse events through collaboration with pharmacist - Facilitating member access to medication(s) by: - Contacting pharmacies to obtain medications refills - Contacting members’ providers to issue new prescriptions and set up appointments when necessary - Facilitating access to medications for members experiencing financial issues - Working with the member’s pharmacy to align refills to help members reduce frequency of pharmacy visits - Documenting the care delivered and communicating information to other providers. - Partners with the pharmacists on the team and other members of the healthcare team to: - Communicate a medication treatment plan - May coordinate and integrate an MTM intervention within the broader healthcare management services being provided to the patient - Partner with community pharmacies to communicate member medication adherence - Performs patient health assessments to collect information regarding: - Patient medication profile including prescription and/or non-prescription medications, and homeopathic/herbal therapy - Barriers leading to poor medication adherence including medication and/or patient-related factors, or access to care - Handles member and provider communications both telephonically and possibly in person. Benefits - Medical, dental and vision coverage - Incentive and recognition programs - Life insurance - 401k contributions (all benefits are subject to eligibility requirements) Company Description WE ARE AN EQUAL OPPORTUNITY EMPLOYER. HF Management Services, LLC complies with all applicable laws and regulations. Applicants and employees are considered for positions and are evaluated without regard to race, color, creed, religion, sex, national origin, sexual orientation, pregnancy, age, disability, genetic information, domestic violence victim status, gender and/or gender identity or expression, military status, veteran status, citizenship or immigration status, height and weight, familial status, marital status, or unemployment status, as well as any other legally protected basis. If you have a disability under the Americans with Disability Act or a similar law and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to careers@Healthfirst.org or calling 212-519-1798. All hiring and recruitment at Healthfirst is transacted with a valid “@healthfirst.org” email address only or from a recruitment firm representing our Company. Healthfirst will never ask you for money during the recruitment or onboarding process. The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.

• Support initiatives to resolve gaps in care through direct provider and member outreach • Ensure that all recommendations are consistent with the latest guidelines or otherwise supported by the clinical compendia • Provide clinical pharmacy support to pharmacy technicians as they conduct outreaches to members regarding med adherence • Collaborate internally with Marketing, IT, and Enterprise Analytics to assist with the creation of strategic digital communication channels for member outreach • Identify and resolve same-day grievances reported by members in a timely manner

Role Description WE ARE AN EQUAL OPPORTUNITY EMPLOYER. HF Management Services, LLC complies with all applicable laws and regulations. Applicants and employees are considered for positions and are evaluated without regard to: - Race - Color - Creed - Religion - Sex - National origin - Sexual orientation - Pregnancy - Age - Disability - Genetic information - Domestic violence victim status - Gender and/or gender identity or expression - Military status - Veteran status - Citizenship or immigration status - Height and weight - Familial status - Marital status - Unemployment status HF Management Services, LLC shall not discriminate against any disabled employee or applicant in regard to any position for which the employee or applicant is otherwise qualified. If you have a disability under the Americans with Disability Act or a similar law and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to careers@Healthfirst.org or calling 212-519-1798. In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within HF Management Services, LLC will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with HF Management Services, LLC. Company Description Know Your Rights All hiring and recruitment at Healthfirst is transacted with a valid “@healthfirst.org” email address only or from a recruitment firm representing our Company. Any recruitment firm representing Healthfirst will readily provide you with the name and contact information of the recruiting professional representing the opportunity you are inquiring about. If you receive a communication from a sender whose domain is not @healthfirst.org, or not one of our recruitment partners, please be aware that those communications are not coming from or authorized by Healthfirst. Healthfirst will never ask you for money during the recruitment or onboarding process.

• 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.

Role Description The Appeals & Grievances (A&G) unit processes member and non-contracted provider appeals for all of HF’s line of businesses which include commercial, Medicaid, dual enrollments, Medicare, and complete care. The Appeals Specialist is the subject matter expert responsible for non-clinical case development and case resolution while ensuring compliance with Federal and/or State regulations. They manage their own caseload and are accountable for investigating and resolving member or non-contracted provider-initiated cases. Key Responsibilities - Responsible for case development and resolution of non-clinical cases, such as certain types of claim denials, member complaints, and member and provider appeals. - Independently research issues. - Reference and understand HF’s internal health plans’ policies and procedures to frame decisions. - Interpret regulations. - Resolve cases and make critical decisions. - Edit and finalize resolution letters. - Manage all duties within regulatory timeframes. - Communicate effectively to hand-off or pick-up work from colleagues. - Work within a framework that measures productivity and quality for each Specialist against expectations. - Work independently exercising judgment starting the case development with the respective internal and external entities in the timeframe prescribed in the Job Aid and/or regulatory timeframes. - Prepare and submit well-documented appeals in accordance with payer guidelines and within timely filing limits. - Identify patterns or trends in denials and provide feedback for leadership for process improvement. - Remain up to date on payer policies, industry regulations, and coding updates to ensure compliance and maximize reimbursement. - Additional duties as assigned. Qualifications - HS Diploma or GED from an accredited institution. - Minimum of two (2) years of work experience in Managed Care Health Insurance Plan. - Experience with appeals for Medicare, Medicaid, Dual enrollment, and commercial Plans end to end. - Claims processing experience with coding criteria is preferred. Requirements - Bachelor’s degree from an accredited institution or relevant work experience. - Demonstrated critical thinking and decision-making competencies. - Demonstrated ability to be detail-oriented, work under pressure, and manage tight timeframes. Benefits - Medical, dental, and vision coverage. - Incentive and recognition programs. - Life insurance. - 401k contributions (all benefits are subject to eligibility requirements). Company Description WE ARE AN EQUAL OPPORTUNITY EMPLOYER. HF Management Services, LLC complies with all applicable laws and regulations. Applicants and employees are considered for positions and are evaluated without regard to race, color, creed, religion, sex, national origin, sexual orientation, pregnancy, age, disability, genetic information, domestic violence victim status, gender and/or gender identity or expression, military status, veteran status, citizenship or immigration status, height and weight, familial status, marital status, or unemployment status, as well as any other legally protected basis. If you have a disability under the Americans with Disability Act or a similar law and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to careers@Healthfirst.org or calling 212-519-1798. Know Your Rights: All hiring and recruitment at Healthfirst is transacted with a valid “@healthfirst.org” email address only or from a recruitment firm representing our Company. Healthfirst will never ask you for money during the recruitment or onboarding process. Hiring Range*: Greater New York City Area (NY, NJ, CT residents): $58,900 - $80,070; All Other Locations (within approved locations): $51,000 - $74,880. In addition to your salary, Healthfirst offers employees a full range of benefits.

Role Description The Clinical Pharmacist is a dynamic position responsible for the review of prior authorization requests for medications requested under the medical benefit. Additionally, the Clinical Pharmacist will be responsible for developing clinical criteria, medical policies for provider administered medications, review of monthly report for quality assurance, and staying current with literature, evidence-based medicine, and trends in medicine. The Clinical Pharmacist will work directly with prescribing physicians and Medical Directors to discuss clinical rationale for review decisions. This position reports to the Director of Pharmacy. Duties & Responsibilities: - Monitor and review prior authorization requests for medications - Calculate appropriate billable units based on dosing based, indication, weight, BMI and other clinical considerations - Develop clinical criteria and medical policies for the review of medications - Ensure all clinical criteria is in compliance with Center of Medicare and Medicaid Services (CMS) and the New York State Department of Health (NYSDOH) - Research drug information to maintain drug knowledge and disease state understanding for application to prior authorization reviews - Ensure prior authorization reviews are conducted in timeframes set forth by CMS and/or NYSDOH - Review monthly reports and provide feedback on trends, ideas for efficiency, and innovation - Ability to work well in a team environment and be a team player - Additional duties as assigned Qualifications - Pharmacy degree from an accredited school of pharmacy - Registered Pharmacist in the state of New York with a license in good standing - Minimum of 1 year experience conducting prior authorization reviews - Strong clinical knowledge of pharmaceuticals and disease states in order to conduct prior authorization reviews - Strong clinical writing and verbal skills - Demonstrated critical thinking and problem-solving skills - Knowledge of specialty pharmaceuticals and billing practices in the medical and pharmacy benefits - Passion for learning, promoting the profession of pharmacy, and interest in growing skills in a dynamic environment with various opportunities Requirements - PGY1 Managed Care Residency (optional) - Knowledge of regulations of the Centers for Medicare and Medicaid Services including but not limited to National and Local Coverage Determinations - Ability to lead large and small working meetings - PC Skills with Microsoft Outlook, Word, PowerPoint (creating presentations and slides), and Excel (Pivot tables) - Licensed pharmacist in the state of NY in good standing Benefits - Medical, dental and vision coverage - Incentive and recognition programs - Life insurance - 401k contributions (all benefits are subject to eligibility requirements) Company Description WE ARE AN EQUAL OPPORTUNITY EMPLOYER. HF Management Services, LLC complies with all applicable laws and regulations. Applicants and employees are considered for positions and are evaluated without regard to race, color, creed, religion, sex, national origin, sexual orientation, pregnancy, age, disability, genetic information, domestic violence victim status, gender and/or gender identity or expression, military status, veteran status, citizenship or immigration status, height and weight, familial status, marital status, or unemployment status, as well as any other legally protected basis. If you have a disability under the Americans with Disability Act or a similar law and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to careers@Healthfirst.org or calling 212-519-1798. Healthfirst will never ask you for money during the recruitment or onboarding process.

• The Service Agent is responsible for supporting Contact Center Operations (CCO) by ensuring members and/or providers receive an exceptional customer experience. • This individual receives and addresses member & provider inquiries, resolves complaints, educates clients, retains members, helps to prevent dis-enrollments, and escalates issues requiring additional intervention across all Lines of Business (LOBs). • Provides excellent quality customer service to our members and/or providers relating to all aspects of member/provider questions and issues. • 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. • Initiates investigations as required, partnering with other assigned parties to participate in root cause analysis. • Complies with HIPAA requirements and maintains Protected Health Information (PHI) confidentiality. • Builds sustainable relationships of trust through open and interactive communication with internal and external customers. • Works a flexible schedule including a late shift, weekends, and/or holidays (with limited notice at times), and as needed during unforeseen business disruptions. • Additional duties as required.

Role Description The Service Agent is responsible for supporting Contact Center Operations (CCO) by ensuring members and/or providers receive an exceptional customer experience. This individual receives and addresses member & provider inquiries, resolves complaints, educates clients, retains members, helps to prevent dis-enrollments, and escalates issues requiring additional intervention across all Lines of Business (LOBs) within our traditional and/or Omni-channel contact center environment. The Service Agent maintains the Healthfirst culture and drives improvements to ensure the best possible customer experience for our North Star Members and the Providers who service them. Duties and Responsibilities - 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. - 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-escalates situations where member/provider is upset and provides resolution for their issue. - Initiates investigations as required, partnering with other assigned parties to participate in root cause analysis, takes proactive and/or corrective measures and/or recommends solutions and methods for process improvement. - Follows up on outstanding customer inquiries and complaints within defined timeframe. - Complies with HIPAA requirements and maintains Protected Health Information (PHI) confidentiality of member, provider, medical and departmental information. - Adheres to local, state, federal and Healthfirst specific compliance and regulatory guidelines. - Builds sustainable relationships of trust through open and interactive communication with internal and external customers. - Works a flexible schedule including a late shift, weekends, and/or holidays (with limited notice at times), and as needed during unforeseen business disruptions. - Additional duties as required. Qualifications - High School Diploma or GED from an accredited institution. - Prior experience in a customer service environment. - Experience participating in cross-functional projects and departmental initiatives related to customer/client interaction and customer service. - Working experience in a fast-paced environment. - Proficient in Microsoft Office Suite applications including Excel, Word, and Outlook. Requirements - Associate’s or Bachelor’s Degree from an accredited institution or equivalent work experience. - Proven track record of exercising independent thinking, problem solving and achieving goals. - Knowledge and experience with a traditional and/or omnichannel contact center with emphasis in the healthcare industry. - Experience navigating multiple technologies including a Customer Relationship Management System. - Basic knowledge of operational health plan departments and functionality. - Working knowledge of Microsoft Office Power Point. - Excellent verbal and written communication and the ability to document grammatically correct emails, communications, and presentations. - Basic understanding of call center metrics including Average Handle Time (AHT), Quality, etc. Benefits - Medical, dental and vision coverage. - Incentive and recognition programs. - Life insurance. - 401k contributions (all benefits are subject to eligibility requirements). - Competitive compensation and benefits package wherever its employees work and live. Company Description WE ARE AN EQUAL OPPORTUNITY EMPLOYER. HF Management Services, LLC complies with all applicable laws and regulations. Applicants and employees are considered for positions and are evaluated without regard to race, color, creed, religion, sex, national origin, sexual orientation, pregnancy, age, disability, genetic information, domestic violence victim status, gender and/or gender identity or expression, military status, veteran status, citizenship or immigration status, height and weight, familial status, marital status, or unemployment status, as well as any other legally protected basis. HF Management Services, LLC shall not discriminate against any disabled employee or applicant in regard to any position for which the employee or applicant is otherwise qualified. If you have a disability under the Americans with Disability Act or a similar law and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to careers@Healthfirst.org or calling 212-519-1798. Know Your Rights: All hiring and recruitment at Healthfirst is transacted with a valid “@healthfirst.org” email address only or from a recruitment firm representing our Company.