Healthfirst

• 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

• 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.

• 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.

• 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)

• 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

• 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

• 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.

• Plans and manages behavioral and/or physical care with members • Conducts assessments to identify barriers and opportunities for intervention • Develops care plans that align with the physician’s treatment plans • Collaborates with provider doctors and community-based service providers • Evaluates service authorizations to ensure alignment and execution of care plans

• Review complex prior authorization, concurrent review, and retrospective cases related to Outpatient Rehab services • Ensure all determinations are rendered within applicable regulatory and internal turnaround timeframes • Conduct peer-to-peer discussions with treating providers as needed • Collaborate with Medical Directors on complex or escalated cases • Participate in annual Inter-Rater Reliability (IRR) testing to ensure consistency and defensibility of determinations • Analyze trends in PT utilization including but not limited to visit frequency and duration patterns • Collaborate with Delivery Systems Engagement on education regarding documentation requirements

• leads and implements best-in-class data management strategies • authors artifacts defining standards and definitions for storing, processing, and moving data • maps details within these artifacts to business processes, non-functional characteristics, qualitative criteria, and technical enablement • finds trends in datasets and develops workflows and algorithms to highlight strategic raw data • creates data acquisition strategy and develops dataset processes in a robust manner