Healthfirst

• 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

• 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

• Responsible for promoting compliance with regulatory requirements with Healthfirst's different departments • Meets with the Regulatory department to organize pre-survey deliverables and conduct reviews of materials • Interacts with and represents the business unit • Responds to auditor requests and audits outcome results • Identifies organizational risks and helps implement process improvements • Manages, coordinates, and participates in the implementation of contract changes for all lines of business • Ensures that all process and contract changes are reflected in departmental policies and procedures • Monitors all Utilization Management/Care Management/Appeals & Grievances corrective action plans (CAPs) through completion • Assists in accreditation submissions, regulatory surveys, and internal audits • Provides support to Pharmacy Department related to regulatory implementation efforts

• Works vertically and horizontally across the Infrastructure and Operations portfolio supporting private/public cloud systems, operating systems, middleware, storage, database platforms, and other key infrastructure products. • Assists department leadership by providing informal coaching and direction to I&O Engineering team • Subject matter expert for advanced analysis and resolution of the most complex issues • Develops repeatable automation to deliver capabilities more efficiently. • Devises solutions to problems impacting mission critical systems and implements automation to prevent reoccurrence. • Supports and implements private cloud Hybrid Cloud Infrastructure (HCI) technologies. • Plays a senior role within a Center of Excellence for cloud usage and cloud development standards. • Maintains an accurate picture of existing server, storage, networking, software and hardware and virtual environments to support scaling against various project requirements. • Ensures all usage of cloud environments meet governance standards and contributes to improving standards for security and operational efficiency. • Creates Standard Operating Procedures (SOPs) for Healthfirst operations teams to support the operations of the products. • Acts as a senior escalation point for operations and delivery teams for incident and ticket resolution and participates in an on-call rotation. • Serves as a technical leader within Infrastructure & Operations as well as with Development teams in areas of Cloud technology and automation.