Healthfirst

Role Description The Appeals & Grievances (A&G) unit manages Healthfirst member complaints, grievances, and appeals that are presented by the member or provider pertaining to the authorization of or delivery of clinical and non-clinical services. A&G works in collaboration with divisions within and outside the organization to resolve issues in a timely and compliant manner. The A&G Clinical Specialist is the subject matter expert responsible for all clinical case development and case resolution while ensuring compliance with Federal and/or State regulations. The incumbent will manage his/her own caseload and is accountable for investigating and resolving member or provider initiated cases. Manages all Department of Health (DOH) and executive complaints as needed. The incumbent may also handle clinical claim appeals that come from Healthfirst participating and non-participating providers. This is either a remote or on-site position located at either the 100 Church Street location in New York City or the 1101 Greenwood Avenue location, Lake Mary, Florida. This position may require attendance at A&G/Operations divisional meetings and Town Halls, some of which may require travel to one of the locations (T&E will be covered according to policy). 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. - 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. - 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. - Work within a framework that measures productivity and quality for each Specialist against expectations. - Prepare cases for Medical Director Review ensuring that all pertinent information (i.e. case summary, contract information, internal and external responses, diagnosis, and CPT codes and descriptions) has been obtained during investigation and is presented as part of the case. - Prepare cases for Maximus Federal Services, Fair Hearing, and External Appeal through all levels of the appeal process. - Additional duties as assigned. Qualifications - RN Preferred Qualifications - Bachelor’s degree. - Experience in clinical practice with experience in appeals & grievances, claims processing, utilization review or utilization management/case management. - Demonstrated understanding of Utilization Review Guidelines (NYS ART 44 and 49 PHL), InterQual, Milliman or Medicare local coverage guidelines. - Ability to work independently on several computer applications such as Microsoft Word and Excel, as well as corporate email and virtual filing system (i.e. Macess). - Experience with care management systems, such as CCMS, TruCare and Hyland. - Demonstrated ability to manage large caseloads and effectively work in a fast-paced environment. 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): $83,100 - $120,360. - All Other Locations (within approved locations): $73,400 - $108,160.

• Assisting care/case managers with non-clinical activities such as creating cases and events • Managing authorizations • Providing telephonic outreach to members, providers and community-based organizations • Handling member mailings • Faxing clinical requests and Individual Health Care Plans on behalf of the care/case managers • Providing excellent quality customer service to members and/or providers relating to authorization updates and scheduling appointments • Managing a large volume of tasks and caseloads from multiple queues • Building sustainable relationships of trust through open communication with internal and external customers • Documenting accurate member information in compliance with internal procedures • Complying with HIPAA requirements and maintaining Protected Health Information (PHI) confidentiality

• Responsible for case development and resolution of non-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 • 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 • Prepare and submit well documented appeals in accordance with payer guidelines • Identify patterns or trends in denials and provide feedback for leadership.

• 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

• 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

• 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

Role Description The Team Lead Support Coordinator oversees a team of Coordinators, ensuring they are providing the appropriate care and services to members. The Team Lead Support Coordinator is assigned to a specific clinical team (such as Care Management, Utilization Management, Behavioral Health, etc.) and may have additional departmental responsibilities. - Supervises the Coordinators activities such as creating cases; assessment screening; admission events; creating referral events within the MIS system; receiving and processing incoming correspondence; preparing and processing outgoing correspondence to members, providers and community organizations. - Oversees, analyzes, and coordinates team members daily activities to ensure that departmental productivity goals are met in regards to quality, timeliness, accuracy, and consistency of medical decisions. - Ensures a team atmosphere that fosters open communication, collaboration, ownership, and empowerment to make decisions. - Coaches and manages review of staff performance. - Supports continuous improvement and quality initiatives that improve processes across departments. - Additional duties as assigned. Qualifications - High School Diploma or GED - Work experience requiring written and verbal communication that is clear, concise, grammatically correct, and professional - Proficient in Microsoft Office Suite applications including Excel, Word, Power Point and Outlook Requirements - Associate’s degree - Excellent communication, time management, critical thinking, and problem solving skills. - Supervisory, training, or management experience - Demonstrated ability to allocate, monitor, and control resources while delegating and monitoring workloads - Demonstrated ability to manage large caseloads in work in a fast-paced environment while building and enhancing team productivity - Demonstrated professionalism and leadership skills along with the ability to develop, direct, and support staff - Familiarity with PHI systems 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. Thank you for considering a career with HF Management Services, LLC.

• 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

• Execute forecasting and capacity planning activities in a multichannel contact center environment • Develop and manage forecasts and staffing plans • Partner with leadership on forecasting processes including data preparation and model updates • Ensure forecasts are accurate and aligned with business inputs • Translate demand into actionable staffing plans and monitor forecast performance • Support ongoing capacity planning and validate assumptions impacting forecasts • Produce regular reporting on forecasts, staffing plans, and KPIs. • Identify opportunities for process improvements in forecasting tools.

• Provides high quality on-line and telephone assistance to all customers including brokers/agent and their uplines • Provides high quality handling of customer inquiries, via mail, e-mail and chat sessions • Resolves inquiries and issues relating to all aspects of broker/ agent business: Broker/Agent questions and issues regarding member eligibility, benefits, claims process, as well as product questions and various other customer support functions • Makes recommendations to management concerning problems, problem trends and process improvement