Healthfirst

47 job(s) at Healthfirst

Healthfirst Lake Mary, FL
Job Description Description The Workforce Management System & Reporting Analyst will be responsible for Contact Center application systems and support geared toward enhancing operational efficiency, quality, productivity and effectiveness. Candidates will assist the leadership team by gathering data, identifying useful information, recommending and supporting decision-making with the goal of departmental improvement. The Workforce Management System & Reporting Analyst owns project goals by developing project plans, establishing deadlines, monitoring milestone completion, providing timely reporting of issues that impact progress and resolving conflicts. They must develop standardized tools, methodologies and business processes aimed at improving operational efficiencies. This position will also include assisting Management as needed with the performance of other duties associated with the day-to-day management of the division.Identify root causes and make recommendations for process improvements to increase efficiency and improve overall productivityAssess, prepare, and address the operational impacts, workflow, and training issues related to any assigned project(s)Provide daily, weekly, and monthly status to the Business Unit(s) via dashboards, reports, and tools including but not limited to Workforce Management Activity, Desktop Process Activity, Data Maintenance Inventory, Payroll/Time Management, Agent/Department Performance, Provider Data Management Program, and Provider Portal ActivityCollaborate with business units to understand strategic goals and promote an environment conducive to creativity, change, and information exchangeParticipate in systems testing and validation for various systems including call center programs, SharePoint, Salesforce and other business-related programsCreate a meaningful interpretation of data through use of tools, industry experience and logic to frame situations and allow meaningful dialogue and decision makingCreate and edit ad-hoc reporting to be used to identify tracks and trends to increase overall operational efficiencies with supported departmentsWork with leadership team on execution or recommended schedule adjustments to meet daily KPIs while also maintaining Key Performance Metrics Scorecards for the business using WFM and customized toolsSupport ad-hoc requests from Leadership as requestedSeek occasional guidance while working under moderate supervision from Team Leads, Managers, SME’s, etc.Other related duties as assignedMinimum QualificationsAssociates degree from an accredited institution or relevant work experienceExperience in Microsoft Excel creating formulas, pivot tables, using macros, creating graphs and producing reports with large volume of dataAbility to gather business requirements, create, execute and control tools to improve the overall operational efficiency of a businessWorking experience with call center computer software applications such as Microsoft Office, SAS, SQL, Salesforce, SharePoint, Verint Workforce Management tool, Desktop Process Analytics, Interactive Intelligence Administrator/Attendant or Crystal Reporting (Need to be familiar with SQL)Working experience using analytical and problem-solving skills; interpreting and summarizing complex data as it relates to call center operation and technologiesExperience presenting reports, forecasts, trends and recommendations to the team and senior management in a clear, concise, and actionable mannerAbility to work effectively and meet deadlines in a rapidly changing environment, while handling multiple projects at a time whether individually or working with a teamPreferred QualificationsBachelors degree from an accredited institution or relevant work experienceHistory of solving problems with some guidance by subject matter experts, management, general organization objectives, policies, and goalsKnowledge of Medicare and Medicaid programs and reimbursement methodologiesKnowledge of healthcare claims processing practices in a managed care settingWE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.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 Healthfirst Management Services will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with Healthfirst Management Services.EEO Law Poster and Supplement
Healthfirst New York, NY
Job Description Description Healthfirst's HR Business Partners are the 'culture architects' for the organization and responsible for delivering human capital solutions that enable the success of our business. A Sr Mgr, HRBP leads and manages the full suite of talent lifecycle activity by partnering with business leaders to deliver solutions developed in concert with colleagues throughout HR. As a member of the business unit/Department management team, the Sr Mgr, HRBP shares responsibility for achieving business goals and delivery targets. The Sr Mgr, HRBP is an experienced HR professional and subject matter expert who has broad experience across a variety of HR specialties. The Sr Mgr, HRBP applies HR expertise, deep knowledge of the assigned business unit, key employees and business processes to deliver value to Healthfirst and its members.Proactively supports the delivery of all HR initiatives and processes.Builds a strong business relationship with the internal client and serves as a key advisor and confidante, enabling strong management and leadership for the Department.Facilitates the design and implementation of "best solutions" that fuel engagement; faster, better, cheaper processes and tools; the health of our population of members; profitable growth and our culture. Actively identifies gaps, proposes and implement changes necessary to cover risks and drive performance (hi-potential; succession planning; performance calibration; corrective action; employee engagement; recognition; rewards; employee integration and development).Influences positive change in people management and designs and maintains the vitality of the business unit.Challenges the organizational structure and approach and proposes impactful change strategies and recommendations (organization design; job definition; job description; market parity).Serves as a role model for the organization's Culture drivers; dreams big and plans wisely; breaks down the walls; thinks critically, speaks up and delivers with pride; inspires through trust and leads by example; is unstoppable.Collaborates with and provides guidance and coaching to HRBP Managers and Specialists.Partners with and supports senior business leaders to develop people strategies to meet operational goals. Engages appropriate HR Centers of Excellence as needed to accomplish projects and programs.Supports a large complex business group and works across multiple business units.Other duties as assignedMinimum Qualifications:Must have a Bachelor's degree from an accredited institution.Previous work experience in corporate HR and strong subject matter expertise in 4 or more of the following core areas: HR Generalist; Compensation; Benefits; Rewards & Recognition; Healthcare Management; Organization Design; Learning & Development; Performance Management; Leadership Development; Recruiting; Talent Sourcing; Employee Engagement; Employee Relations; Succession Planning.Conversant with Labor Law and knowledgeable about marketplace HR trends.Proven effective in developing trust and building partnerships at the Division/Business unit level.Critical thinker with demonstrated analytical and problem solving skills.Preferred Qualifications:Prior experience as an HRBPProven written, verbal and presentation skillsProject Management and Change Management skillsStrong Business AcumenStrong Time Management and Priorities Management skillsQuick StudyActive ListenerWE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.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 Healthfirst Management Services will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with Healthfirst Management Services.EEO Law Poster and Supplement
Healthfirst New York, NY
Job Description Description Position Summary:The Senior Actuarial Analyst for Valuations is responsible for assisting in performing valuations, producing IBNR models, analyzing experience, preparing trend reports, and assisting with other tasks on both a regular and ad-hoc basis.Duties and Responsibilities:Construct monthly IBNR models using paid claim and membership dataRun, modify, and create data queries to produce supplemental reportsInitiate, oversee, and verify information exchanges between actuarial models and Data WarehouseProduce and maintain trend reportsModify or add models as needed for changing business needsWork on data incorporated into high level corporate reporting and monitor experience of all lines of businessProvide other data analysis as required by managementMentoring junior-level team membersRequired Qualifications:Bachelor’s degree in Actuarial Science, Math, Economics, Finance or any related degreeStrong Excel skills, including ability to create pivot tables, v-lookups, graphs/visuals and perform troubleshootingExperience with programming/coding, preferably SAS or SQLAbility to collect, analyze and summarize qualitative/quantitative dataExperiencing working with large and complex datasets, including both financial and healthcare dataExperience with forecast/pricing and relevant methodologies, IBNR analysis, trend analysis, product and segment analysisWork experience within Managed Care, Medicare/Commercial Healthcare or Hospital in the actuarial fieldStrong planning and organizational skillsStrategic thinker, creative, innovative, and execution focused turning ideas into measurable meaningful resultsTeam player, ability to work as a team with actuaries and non-actuaries to solve problems and deliver resultsAbility to work on multiple projectsExceptional verbal and written communication skillsPreferred Qualifications:Passed 2+ Actuarial Exams, working towards ASA designationCompliance & Regulatory Responsibilities: N/ALicense/Certification: NAWE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.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 Healthfirst Management Services will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with Healthfirst Management Services.EEO Law Poster and Supplement
Healthfirst New York, NY
Job Description Description The Senior Data Scientist is responsible for defining, building, and improving statistical models to improve business processes and outcomes in one or more healthcare domains such as Clinical, Enrollment, Claims, and Finance. As part of the broader analytics team, Data Scientist will gather and analyze data to solve and address complex business problems and evaluate scenarios to make predictions on future outcomes and work with the business to communicate and support decision-making. This position requires strong analytical skills and experience in analytic methods including multivariate regressions, hierarchical linear models, regression trees, clustering methods and other complex statistical techniques.Duties & Responsibilities:• Develops advanced statistical models to predict, quantify or forecast various operational and performance metrics in multiple healthcare domains• Investigates, recommends, and initiates acquisition of new data resources from internal and external sources• Works with multiple teams to support data collection, integration, and retention requirements based on business needs• Identifies critical and emerging technologies that will support and extend quantitative analytic capabilities• Collaborates with business subject matter experts to select relevant sources of information• Develops expertise with multiple machine learning algorithms and data science techniques, such as exploratory data analysis and predictive modeling, graph theory, recommender systems, text analytics and validation• Develops expertise with Healthfirst datasets, data repositories, and data movement processes• Assists on projects/requests and may lead specific tasks within the project scope• Prepares and manipulates data for use in development of statistical models• Other duties as assignedMinimum Qualifications:-Bachelor's DegreePreferred Qualifications:- Master’s degree in Computer Science or Statistics- Familiarity with major cloud platforms such as AWS and Azure- Healthcare Industry ExperienceMinimum Qualifications:-Bachelor's DegreePreferred Qualifications:- Master’s degree in Computer Science or Statistics- Familiarity with major cloud platforms such as AWS and Azure- Healthcare Industry ExperienceWE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.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 Healthfirst Management Services will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with Healthfirst Management Services.EEO Law Poster and Supplement
Healthfirst New York, NY
Job Description Description The Senior Healthcare Analyst is responsible for monitoring risk pool performance, communicating financial results and identifying areas of opportunity for Healthfirst and hospital senior management. The Senior Healthcare Analyst will contribute to a broad set of projects across the department. Produce and manage performance reports of value-based risk share agreements. Model risk contracts and provider reimbursement changes Monitor costs and revenue trends for healthcare providers and identify root cause of developing trends. Understand and analyze impacts of new program changes such as new benefits or new populations. Prepare monthly analysis for analytic council meetings and stakeholders. Respond to requests for analysis and provide analytic support to various stakeholders and departments. Pull data from warehouse using Statistical Analysis System (SAS)/Structured Query Language (SQL) code/Python (or similar programs) and create reports in tableau or excel. Manage and organize meetings to discuss analysis requests, inform stakeholders on the latest financial trends, and to keep abreast of the changes occurring in our provider community. Keep abreast of New York Medicaid and Medicare reforms and their impact on the health plan and owner hospital performance. Assist in training and development of analysts  Additional Job Description Experience in supporting Network Management analytical requests. Experience in presenting analysis to internal and external stakeholders. Self-motivated, creative problem solver who can work independently and collaborate through strong communication and interpersonal skills. Strong project management experience and ability to handle multiple projects in a fast-paced environment. Minimum Qualifications:  Bachelor’s degree from an accredited institution.  3+ years of analytical work experience within the healthcare industry (i.e. hospitals, network, ancillary, medical facilities, healthcare vendor, commercial health insurance company, large physician practices, managed care organization, etc.)  Work experience with SAS and/or SQL where you have created queries, pulled large data sets and performed data manipulations/analysis.  Experience with MS Excel functions that include working with large data sets, creating standardized reports, utilizing vLookups and advanced functions/ formulas; creating, using and interpreting pivot tables, filtering and formatting.  Knowledge of healthcare financial terms such as cost, utilization, Per Member Per Month (PMPM) and revenue.  Basic understanding of Medicaid and Medicare programs or other healthcare plans.  Self-motivated, creative problem solver who can work independently and collaborate through strong communication and interpersonal skills.   Preferred Qualifications:  Bachelor’s degree in Finance, Math, Statistics or Computer Science from an accredited institution Strong project management experience and ability to handle multiple projects in a fast paced environmentDemonstrated understanding of key managed care concepts and provider reimbursement principles such as risk adjustment, capitation, FFS (Fee-for-Service), Diagnosis Related Groups (DRG’s), Ambulatory Patient Groups (APG’s), Ambulatory Payment Classifications (APC’s), and other payment mechanisms  Understanding of value-based risk arrangements Experience using TableauWE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.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 Healthfirst Management Services will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with Healthfirst Management Services.EEO Law Poster and Supplement
Healthfirst New York, NY
Job Description Description The Senior Media Manager is responsible for planning, buying, and overseeing media that translates the brand’s marketing and advertising objectives into a well thought|out, strategic, cross|platform media campaign. This includes working with business partners on media briefs, analyzing program results, and managing media agencies and vendors. The Senior Media Manager is the leader in the development of annual and seasonal media strategies, and will work in concert with other marketing and cross|functional partners to deliver a comprehensive media plans that meet business objectives. This person will partner closely with Brand Activation, Digital and Social Media teams for consistency of digital, experiential and media strategy.Oversee media plan creation to ensure proposals speak directly to company objectives and address target audiences appropriatelyManage media vendors and negotiate contractsClosely monitor live campaigns and work with team & vendors to ensure KPIs are being met. Make optimization recommendations when necessaryWith strategy leads & internal clients, develop media plan requirements, pricing, campaign measurement KPIs, and moreEngage in industry trades and with peers to coordinate offline & online media and stay abreast of all media trends and challengesBe solution-oriented and creative as new challenges ariseSuccessfully work across internal departments and develop collaborative relationships with department headsWork with media vendors to collect and communicate creative deadlinesCommunicate and help manage timelines to ensure on time deliveryMinimum Qualifications:Strong work ethic, attention to detail, ability to effectively manage time, and commitment to developing quality work quicklyExceptional communication skills and executive presenceKnowledge of health insuranceSolid understanding of direct acquisition and retention marketing and the metrics used to measure successUnderstanding of the New York metro marketplace and its diverse communitiesMulti-cultural or grass-root marketing experienceDirect Marketing experienceExperience tracking and measuring marketing and advertising campaignsWE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.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 Healthfirst Management Services will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with Healthfirst Management Services.EEO Law Poster and Supplement
Healthfirst New York, NY
Job Description Description The Developer’s primary responsibilities are to analyze, design, implement and test customized software applications. The Developer should have essential knowledge of software development and design, is a quick learner and should have passion to refine him/herself by adopting new development skills. The Developer should be flexible and willing to learn new programming skills and should be able to migrate existing solutions from one development stack to another based on organization roadmap.Self-motivated Web Developer to fill a combined role of both front end and back end development tasks. The tasks will include developing lightweight front end web sites to work in conjunction with backend API's and Web Services using MVC frameworks and custom written libraries.Duties & Responsibilities:Designs, develops, and maintains complex applicationsDevelops unit tests and provides code coverage to accurately test business logic and functionalityParticipates in developing specifications such as user stories and designsSolves or recommends solutions for complex issues and problemsAssist in the development of logical and physical specificationsDocuments designs, issues, solutions, tips & tricks as neededFosters a team approach to software development and deliveryStays current in new IT technologies to maintain a high level of subject matter expertise.Other duties as assignedMinimum Qualifications:HS Diploma or GED from an accredited institutionBachelor's Degree or equivalent experience Experience building web applications, using combinations of PHP, Laravel (or similar MVC framework), Javascript, and Angular Strong SQL skillsAPI integration and/or development experiencePreferred Qualifications:Healthcare experienceExperience working with CI/CD using JenkinsExperience working with GIT for version control and content deploymentKnowledge of Mulesoft and building integrations with SalesforcePrior experience integrating with backend systemsPractical knowledge of XML and Web Services (REST, SOAP)Some knowledge of UNIX shell skillsExperience in Agile environments and methodologiesWE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.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 Healthfirst Management Services will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with Healthfirst Management Services.EEO Law Poster and Supplement
Healthfirst Lake Mary, FL
Job Description Description The Sr. Manager Application Development will be responsible for leading the team that manages the daily operations of the Pega Platform solutions at Healthfirst. This individual will be responsible for coordinating a cross functional team – including Infrastructure & Operations, Business Operations, Application Development, and subject matter experts from various domains. This role will also be responsible for guiding the design and development of new solutions or significant enhancement of existing technology assets that support the enterprise orchestration platform and solutions across the business operations processes. This includes ensuring current best practices around performance, scalability and compliance are followed while also meeting current and future business needs. This role will interface with the Enterprise Architecture and Program Delivery teams to deliver technical solutions to complex problems that require the regular use of ingenuity and creativity. The individual at this level will embody Healthfirst’s Culture Drivers through his/her workplace behavior.Establish and maintain IT leadership and business partnershipsAccountable to the business and IT leadership for successful service delivery, delivering superior service management for the Pega PlatformPosition team to communicate with business in business terms rather than technical terms and increase the teams’ business acumenSoftware Design and Implementation for both integration platforms and core transactional systemsServe as a technical lead for architecture, design, implementation and interface decisions related to BPM and core business operations solutions.Work with the team members and across IT and business organization to influence overall Software development, application integration and implementation strategy and development direction.Drive the design methodology of the software development process using SAFe Agile methodology.Assess feasibility and ramifications of new business requirements. Design appropriate solutions and recommend alternative approaches when necessary.Stay abreast of advancements in modern world technologies in order to determine relevance and possible impact to existing system as well as future development path.Recommend and implement engineering best practices, including use of design patterns, code reviews and automated unit testing.Develop and mature process for high level and detail estimation for schedule and budget for integration.Act as the Senior Solution architect and or service delivery lead on major initiativesAbility to lead team and work with Business group, Enterprise Architecture team and other technology groups within the organization in managing the overall directions and implementation of orchestration and integration services for enterpriseMinimum Qualifications:Bachelor's Degree from an accredited college or University.8-10 years in a leadership role managing resources and driving the strategy and outcomesStrong knowledge of professional services vendors, and outsourcing business models and tools  Management of medium (10+) to large teams Experience in implementing quality guidelines, standards and proceduresExperience working in Agile delivery model Preferred Qualifications:Cloud Based technology stackExposure to PEGA technologiesWE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.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 Healthfirst Management Services will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with Healthfirst Management Services.EEO Law Poster and Supplement
Healthfirst New York, NY
Job Description Description The Quality Assurance Team Lead oversees quality monitoring function and is responsible for assuring that standards are being evaluated fairly and consistently. In this role the QA Team Lead will be responsible for leading a team of auditors to conduct compliance and operational audits to identify areas of risk and make recommendations to help improve operational efficiency and effectiveness as well as ensuring compliance with applicable laws and procedures.Evaluate the design and effectiveness of controls to mitigate risks to the organization to an acceptable level as determined by Management.Supervise and assist a team of auditors to ensure completion of audit activities of key business processes for compliance with key controls, plans, policies, procedures, regulatory requirements and best practices.Supervise and control the full audit cycle including risk management and control management over operations’ effectiveness, financial reliability and compliance with all applicable directives and regulations.Ensure productivity & accuracy of auditors meet or exceed department standards.Supervise team to ensure time and attendance are properly managed and over time targets are achieved.Supervise, coach and develop a team of auditors to ensure consistent growth and ongoing operations.Obtain, analyze and evaluate process documentation, previous reports, data, flowcharts, etc.Identify variances, prepare detailed explanations, and correspond with employees, management, etc. as needed to resolve discrepancies.Identify improvements to systems, procedures and processes to minimize risks, improve efficiency, or generate cost savings.Apply analytical skills and knowledge of current auditing developments and standards to formulate appropriate solutions to problems.Accurately document audit work performed to support conclusions reached.Prepare and present reports that reflect audit’s results and document process.Conduct follow up audits to monitor management’s interventions.Develop an understanding of HealthFirst’s business, risk landscape, financials, processes and control environment.Develop knowledge regarding industry rules, regulations, best practices, tools, techniques and performance standards.Maintain open communication with management and business leaders with regards to QA assessments, findings and recommended improvements that are independently derived through applying QA & Audit standards. Support external auditors as assigned.Perform special projects as needed.Perform call monitoring of incoming and/or outgoing calls to confirm standards are met, ID performance gaps, and analyze errors to determine root causes.Other duties as assigned.Minimum Qualifications:Ability to lead by example, guide & direct a team, answer questions, maintain positive morale, break down barriers to success, and execute against Management’s goals and objectives.Experience leading teams and/or projects to consistently meet or exceed deadlines and objectives.Ability to understand and implement internal control concepts and perform root cause analysis to solve complex problems.Knowledge of accepted principles and practices of auditing, following written audit programs, and preparing adequate working papers to document audit work performed and conclusions reached.Ability to communicate effectively, both orally and in writing, with peers, managers, and the public, on both individual and group levels.Advanced computer skills on MS Office (i.e., Excel, Word, PowerPoint).Technical and data management skills including ability to identify, obtain, format, model, manipulate, and analyze large amounts of data and compile detailed reports / dashboards.Ability to effectively plan, organize, prioritize and complete work assignments/projects.Exercise discretion, good judgment, strong attention to detail, courtesy, tact and patience.Strong interpersonal skills; establishes and maintains good working relationships.Ability to work independently and meet multiple deadlines.Ability to analyze problems with detail and accuracy, keep complex records, assemble and organize data, and prepare reports from such data.BS degree in Accounting, Finance, or Business Administration or equivalent work experience.High ethical standards and values with ability to handle confidential / sensitive issues and information with the highest degree of professional responsibility.Preferred Qualifications:Experience working in auditing, process improvement, or related field preferred.Experience with process mapping, risk assessment, and audit tools.Experience with data analytic software (SQL, ACL, Alteryx, Tableau).Familiarity with GAAP, COSO, SOX and other audit principles preferred.Knowledge of at least two or more lines of business such as Medicare NY, Medicaid, Child Health Plus, QHP, EP, HARP.WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.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 Healthfirst Management Services will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with Healthfirst Management Services.EEO Law Poster and Supplement
Healthfirst New York, NY
Job Description Description The VP, Care Management is responsible for providing the strategic guidance, direction and overall management of the Care Management function and processes across Healthfirst products. This position oversees efforts to improve member outcomes – in functional capability, health services utilization, quality of life, and other important outcomes as measured by external quality measurement programs. The VP seeks to improve the member experience with healthcare services and with the care management process. He/she provides leadership to manage administrative costs for his/her areas, and uses data and metrics to drive constant process improvement.Sets the strategy, direction and goals for all of the Management function with an eye towards quality of service, productivity and process improvement.Serves as the subject matter expert (SME) for care management contributing to interpretation and guidance for new and emerging rules and regulations at both the state and federal levelPartners with other clinical and operational leaders to drive consistency in process and member experience across Healthfirst departments. Uses internal and external benchmarks to drive high-quality outcomes and efficient processes.Actively participates in driving Quality and Population Health improvement efforts within care management teams and more broadly across the organization.Ensures compliance with all organizational policies, procedures and regulatory requirements on behalf of the Care Management function.Builds a high performing team that is organized and staffed effectively.Integrates the Care Management function into Utilization Management and other department workflows to support the coordination of care.Informs policy, product and process decisions across HF from the CM perspective.Additional duties as assignedRegulatory or Compliance activities: Ensures compliance with all organizational policies, procedures and regulatory requirements on behalf of the Care Management function.Minimum Qualifications:A  licensed Registered Nurse in New York or eligible10 years of experience within Care Management5 years of direct leadership experienceExperience within a Matrixed organizationPreferred Qualifications:BSNLeadership experience in Care ManagementWork experience providing mid to long-term strategic and tactical direction and operational oversightExperience managing and developing large teams Experience within realty based leadershipProgressive leadership experience in a health care environmentKnowledge of Managed Long Term Care, Medicare, and Mainstream Medicaid health-care regulations, legislation and lawsExceptional problem-solving; process-oriented yet flexibleDemonstrated ability to work independently and to manage multiple tasks and responsibilitiesExcellent communication skills with the ability to effectively communicate to a wide range of audiencesAbility to work in a fast-paced environment and enhance team productivityExperience working with clinical professionals (nurses, doctors, etc.)Experience in managed care or the healthcare industryNursing degree from an accredited program and New York State Registered Professional Nurse license.WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.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 Healthfirst Management Services will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with Healthfirst Management Services.EEO Law Poster and Supplement
Healthfirst New York, NY
Job Description Description Positioned within the Medical Economics department, the Medical Cost team values, implements, and tracks initiatives aimed at producing savings and bending cost trends. The team is empowered with the resources it needs to produce results and deliver impactful business recommendations. As a Senior Medical Economics Analyst, you’ll map out and construct detailed analyses, confront challenging and unfamiliar subjects, and interface with stakeholders across all departments and lines of business. The conclusions you reach have the potential to improve and influence the organization, playing an essential part in our mission to provide members with affordable and accessible high quality care. Each day you’ll tackle new and unique questions, learning and growing as you develop strategies, find solutions, and build innovative new approaches that support our goals and drive success.The role involves managing projects from analysis to implementation and beyond, ensuring that results are achieved and leadership is aware of the unique headwinds and tailwinds faced by any initiative. The ability to simplify complex scenarios into key takeaways is essential, as is the ability to explain and drill into any given detail behind the analyses you create. You’ll be expected to make independent decisions and support them under scrutiny. Potential areas of analysis include payment policy, utilization management, and value-based payment arrangements. The ideal candidate will be eager to learn, excited to grow, ready for a challenge, and able to thrive in a collaborative and collegial work environment.Job Description & Duties:Value new medical cost initiatives, applying financial modeling expertise and using independent judgement to determine the best methods and approaches to calculate accurate estimates of program savings.Provide data driven analysis to Finance, Claims, Medical Management, Network and other departments to enable critical decision making.Coordinate program implementation with initiative owners and establish controls to validate that changes have occurred.Thoroughly vet and perform due diligence on potential value based arrangements to assess financial impact, ensure operational feasibility, and identify impact on existing programs.Identify favorable and unfavorable performance trends within medical cost initiatives, communicate trends to leadership, and recommend changes to initiative owners to improve performance.Perform complex return on investment analyses for vendors to determine if their financial and clinical performance is achieving desired results.Keep abreast of New York Medicaid and Medicare reforms and their impact on Healthfirst and their owner hospital performance.Minimum Qualifications: Bachelor’s degree from an accredited institution.Analytical work experience within the healthcare industry (i.e. hospitals, network, ancillary, medical facilities, healthcare vendor, commercial health insurance company, large physician practices, managed care organization, etc.)Work experience with SAS and/or SQL where you have created queries, pulled large data sets and performed data manipulations/analysis.Experience with MS Excel functions that include working with large data sets, creating standardized reports, utilizing vLookups and advanced functions/ formulas; creating, using and interpreting pivot tables, filtering and formatting.Knowledge of healthcare financial terms such as cost, utilization, Per Member Per Month (PMPM) and revenue.Basic understanding of Medicaid and Medicare programs or other healthcare plans.Self-motivated, creative problem solver who can work independently and collaborate through strong communication and interpersonal skills.Preferred Qualifications: Strong project management experience and ability to handle multiple projects in a fast paced environment.Demonstrated understanding of key managed care concepts and provider reimbursement principles such as risk adjustment, capitation, FFS (Fee-for-Service), Diagnosis Related Groups (DRG’s), Ambulatory Patient Groups (APG’s), Ambulatory Payment Classifications (APC’s), and other payment mechanisms.Understanding of value based risk arrangements.Experience using Tableau.WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.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 Healthfirst Management Services will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with Healthfirst Management Services.EEO Law Poster and Supplement
Healthfirst Lake Mary, FL
Job Description Description The QA Audit Manager oversees quality monitoring functions and is responsible for assuring that standards are being evaluated fairly and consistently in compliance with policies, procedures, and quality standards in all Healthfirst Operations processes and supporting systems as well as conduct compliance and operational audits to identify areas of risk and make recommendations to help improve operational efficiency and effectiveness. The QA Manager demonstrates understanding and applicability of different Quality Management methodologies and Problem-Tracking & Feedback Loop while also building constructive relationships with Operations process owners.Duties and ResponsibilitiesEvaluate the design and effectiveness of controls to manage risk within our risk appetite and tolerance leveraging standard industry practices to include the preparation and delivery of formal communications expressing opinions and providing insight on the adequacy and effectiveness of business processes and controlsSupport cross functional risk assessment activities to identify, assess and address key risks across various operational areas and to prepare the internal audit planSupervise and control the full audit cycle including risk management and control management over operations’ effectiveness, financial reliability and compliance with all applicable directives and regulationsIndependently create professional reports & dashboards, manage meetings/schedules, root cause and review issues, collaborate with leaders, facilitate discussions to align on corrective actions, and follow up with Management to ensure actions are taken timely as agreedResponsible for overall development and execution of process reviews/audits which includes identifying scope, developing audit programs, mapping processes, reviewing work papers, finalizing audit reports, as well as obtaining and monitoring management action plansProvide recommendations and participate/lead initiatives to enhance the audit processesDevelop recommendations that are actionable and agreed to by management and follow-up to ensure appropriate completionPlan, coordinate and execute core assurance and business assessment activitiesSupervise and assist a team of auditors to ensure completion of audit activities of various groups for compliance with key controls compliance with plans, policies, procedures, regulatory requirements, and best practices.Ensure productivity & accuracy of a team of auditors to meet or exceed department standards.Supervise team to ensure time and attendance are properly managed and over time targets are achieved.Supervise, coach, evaluate and develop individuals on a variety of work-related issues toward the continual improvement and overall management of performance within the department.Maintain open communication and a strong network with management and business leaders regarding QA assessments, findings and recommended improvements that are independently derived through applying QA & Audit standards. Manage call monitoring of incoming and/or outgoing calls to confirm standards are met, ID performance gaps, and analyze errors to determine root causesAssess, evaluate, and promote compliance to internal policiesStay abreast of best practices both internally and externally and provide a conduit for introducing those practices to the organizationDevelop and deliver training on various audit and process improvement topicsSupport strategic business initiatives to continuously improve internal processes that optimize internal controls and reduce total cost of controlsSupport external auditors as assignedPerform special projects as neededOther duties as assignedMinimum RequirementsKnowledge of accepted principles and practices of auditing, following written audit programs, and preparing adequate working papers to document audit work performed and conclusions reached.Experience with process mapping, risk assessment, and audit tools.Must demonstrate ability to understand and implement internal control concepts and perform root cause analysis to solve complex problems.Demonstrated experience leading a team of QA auditors or an operational team and maintain positive morale as well as break down barriers to success.Technical and data management skills including ability to identify, obtain, format, model, manipulate, and analyze large amounts of data and compile detailed reports / dashboards.Advanced computer skills on MS Office (i.e., Excel, Word, PowerPoint). Skilled in creating documents, V-lookups and pivot tables within Microsoft ExcelHigh ethical standards and values with ability to handle confidential/sensitive issues and information with the highest degree of professional responsibility.Must exercise accuracy, discretion, good judgment, strong attention to detail, courtesy, tact, and patience.Ability to effectively plan, organize, prioritize, and complete work assignments/projects.Ability to communicate effectively, both orally and in writing, with peers, managers, and the public, on both individual and group levels.Ability to work independently and meet multiple deadlines.Bachelor's degree from an accredited institution or equivalent work experiencePreferred QualificationsFamiliarity with GAAP, COSO, SOX and other audit principles preferredExperience with data analytic software (SQL, ACL, Alteryx, Tableau)Knowledge of at least two or more lines of business such as Medicare NY, Medicaid, Child Health Plus, QHP, EP, HARPBachelor's degree in  Accounting, Finance, or Business Administration  from an accredited institution preferredWE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.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 Healthfirst Management Services will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with Healthfirst Management Services.EEO Law Poster and Supplement
Healthfirst Lake Mary, FL
Job Description Description The Provider Outreach Specialist performs outbound calls to providers to ensure compliance with Access & Availability standards in accordance with State regulatory requirements. They are also expected to assist with inbound Provider Service calls as needed during time of peak call intervals and/or unexpected call volume spikes.Make outbound calls to Healthfirst network providers to validate member access to services and existing demographic information currently contained in the Healthfirst Provider Database in accordance with Access and Availability surveys and Provider Spot checks.Record responses and initiate database updates accordingly.Successfully complete Provider Services New Hire Training in order to Provide phone support as needed to the Provider Services Unit during times of peak call volume and/or unexpected call spikes.Compile survey results for distribution to DSE – Delivery System Engagement (Network Management) and Provider Operations. Coordinate printing and mailing of non-compliant letters to corresponding Providers.      Field inbound telephone calls from providers, answer their questions, resolve their problems, escalate issues requiring management intervention, and document all actions.   As needed, complete MACESS Service Form inventory for any Provider Operations/Services folders/workgroups as assigned by management, including completion of new Provider loads or assisting with large ad-hoc data entry projects.   Additional duties as assigned.            Minimum Qualifications:High School Diploma or GED equivalent from an accredited school.Working experience making outbound calls to clients and provide proactive follow up to internal support groups.Working experience working as a liaison with providers and internal support groups. Working experience meeting deadlines under time sensitive constraints.  Working experience adapting to last minute project requests and changes to existing processes.Working experience working independently with minimal supervision.Working experience in MS Excel utilizing pivot tables, sorting, filtering, manipulating data and documenting follow up results.Working experience navigating through multiple systems and applications at once.Preferred Qualifications:Associate's Degree from an accredited institution.Working experience in an outbound customer service capacity dealing with direct consumer and/or business to business interactions either over the phone, in-person or written.Customer Service experience in the Healthcare industry and/or at Healthfirst.Working experience as a Provider Services Representative at Healthfirst with a minimum call quality average of 95% or better during past 6 months.Customer Service experience in a Call Center environment.Working experience with Outbound calling campaign's in a Call Center environment.Working experience with MS Excel using Pivot tables.Detailed oriented with organizational skills, with ability to give details in concise manner.SharePoint experience a plus.Compliance & Regulatory Responsibilities: N/ALicense/Certification: NAWE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.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 Healthfirst Management Services will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with Healthfirst Management Services.EEO Law Poster and Supplement
Healthfirst New York, NY
Job Description Description The Learning Delivery Specialist will act as an ambassador in fostering the HF culture and supporting the implementation and delivery of content relevant to enterprise initiatives, business units and strategy. This individual will lead and support learning projects and will be responsible for researching, designing, developing, updating and facilitating classroom and virtual delivery learning events, while partnering with subject matter experts from the business to do so.Facilitate and deliver learning events to support  the enterprise inclusive of all business units.Serve as subject matter expert (SME) in the design and development of learning content partnering with business leaders and the instructional design group.Assist with maintaining and updating all learning content materials, ensuring they meet state, federal or organizational criteria.Partner and consult with internal organizations to create and execute training plansCollaborate and communicate with numerous business units across the enterprise in order to support and help drive change initiatives across the organization.Anticipate training development or delivery challenges and work with business owners to identify mitigation strategies.Manage learning environment to assess, evaluate and communicate learner content/knowledge transfer and skills application.Complete any learning event logistics tasks  and communications to ensure successful delivery and implementation of contentStay current on assigned business unit policies and proceduresUtilize all systems and technology to deliver learning, record any data points and produce reports as needed associated with the execution and sustainability for each learning event.Contribute to the overall success of the Learning organization by identifying ways to continuously improve the learning process and create leaner evaluations that are used to influence current and future offerings.Lead meaningful change and process effectiveness through continuous focus and improvement.Act as a subject matter expert for process document creation.Additional responsibilities as assigned.WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.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 Healthfirst Management Services will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with Healthfirst Management Services.EEO Law Poster and Supplement
Healthfirst New York, NY
Job Description Description The Manager Appeals & Grievances serves as the advanced level subject matter expert for determination of non-clinical and/or clinical matters. The Manager supervises day-to-day departmental activities including, but not limited to, oversight of staff and the A&G processes.- Maintains staff productivity, effectiveness and efficiency. The A&G Manger is responsible for responding to all staff questions regarding A&G processes and timeframes. The Manager assigns workloads and manages staff productivity by randomly auditing and reviewing work assignments.- Monitors quality of records via monthly audits of staff cases. The A&G Manager performs monthly audits of staff cases to ensure that all regulatory timeframes are met and that staff is adhering to departmental policies and workflows.- Conducts monthly staff meetings to update staff on new policies and reinforce current policies within the department.- Supervises and assists with training of new staff and attend Partnership trainings (requires travel within NY Tri-State). Participate in all aspects of personnel management to ensure appropriate staffing, orientation, support, discipline and timely performance appraisals. Ensure that probationary and annual performance appraisals are completed in an objective manner; that employees are encouraged to complete their self-evaluation and that appraisals are completed in a timely manner. Meet regularly with direct reports to review goals, trends and performance measures and to facilitate change.- Develops reports necessary to monitor/track operational efficiency.- Additional duties as assignedMinimum Qualifications:NYS RN Preferred Qualifications:Previous relevant work experienceSupervisory or training experienceDemonstrated professionalism and leadership skills along with ability to develop, direct, and support a team Time management, critical/creative thinking, communication, and problem-solving skillsAdept at planning, organizing, and executingAbility to build and enhance team productivityWE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.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 Healthfirst Management Services will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with Healthfirst Management Services.EEO Law Poster and Supplement
Healthfirst New York, NY
Job Description Description Positioned within the Medical Economics department, the Medical Cost team values, implements, and tracks initiatives aimed at producing savings and bending trends. The team is empowered with the resources it needs to produce results and deliver impactful business recommendations. As a Medical Economics Analyst, you’ll use your strong data and analytical skills to improve and influence the organization, playing an essential part in our mission to provide members with affordable and accessible high quality care. Our team touches all aspects of the Healthfirst business—every product and every department. Each day you’ll tackle new and unique questions, learning and growing as you develop strategies, find solutions, and build innovative new approaches that support our goals and drive success.The role is both big picture and detail oriented. The ability to simplify complex scenarios into key takeaways is essential, as is the ability to explain and drill into any given detail behind the analyses you create. You’ll be expected to make independent decisions and support them under scrutiny. Potential areas of analysis include payment policy, utilization management, and value-based payment arrangements. The ideal candidate will be eager to learn, excited to grow, ready for a challenge, and able to thrive in a collaborative and collegial work environment.Duties & Responsibilities:Value new medical cost initiatives, building from existing analyses or developing new methods and approaches to calculate accurate estimates of program savings.Coordinate program implementation with initiative owners and establish controls to validate that changes have occurred.Identify favorable and unfavorable performance trends within medical cost initiatives, develop recommendations to improve performance, and provide recommendations to initiative owners.Track savings variances to budget and communicate performance to senior leadership.Create financial models to evaluate the impact of provider reimbursement changes.Support Medical Management by assisting with Return on Investment analyses for vendors to determine if their financial and clinical performance is achieving desired results.Provide analytical support for the Claims, Ancillary, Medical Management and Provider Network departments.Keep abreast of New York Medicaid and Medicare reforms and their impact on Healthfirst and their owner hospital performance.Minimum Qualifications:Bachelor’s degree from an accredited institution.Analytical work experience within the healthcare industry (i.e. hospitals, network, ancillary, medical facilities, healthcare vendor, commercial health insurance company, large physician practices, managed care organization, etc.)Work experience with SAS and/or SQL where you have created queries, pulled large data sets and performed data manipulations/analysis.Experience with MS Excel functions that include working with large data sets, creating standardized reports, utilizing vLookups and advanced functions/ formulas; creating, using and interpreting pivot tables, filtering and formatting.Knowledge of healthcare financial terms such as cost, utilization, Per Member Per Month (PMPM) and revenue.Basic understanding of Medicaid and Medicare programs or other healthcare plans.Preferred Qualifications:Bachelor's degree or higher from an accredited institution with a concentration in Finance, Accounting, Business, or Healthcare AdministrationExperience in modeling financial impact of provider reimbursement changes. Self-motivated, creative problem solver who can work independently and collaborate through strong communication and interpersonal skills. Strong project management experience and ability to handle multiple projects in a fast paced environment. Demonstrated understanding of key managed care concepts and provider reimbursement principles such as risk adjustment, capitation, FFS (Fee-for-Service), Diagnosis Related Groups (DRG’s), Ambulatory Patient Groups (APG’s), Ambulatory Payment Classifications (APC’s), and other payment mechanisms. WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.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 Healthfirst Management Services will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with Healthfirst Management Services.EEO Law Poster and Supplement
Healthfirst New York, NY
Job Description Description The Medicare Sales Specialist is a position for top performing Medicare Sales Agents in the NY market. The individual is responsible for identifying prospective Medicare Advantage (MA) beneficiaries, self- generating leads, educating and enrolling beneficiaries in the appropriate MA plan by explaining program benefits in a manner that is compliant with the Center for Medicaid and Medicare Services (CMS) and company policies and regulations. This role will come with a higher quota and a competitive sales incentive plan. This individual will be goal oriented and an expert at self-generating sales activities and possess a deep understanding and extensive experience in community engagement and grassroots marketing. S/he will customarily and regularly work away from Healthfirst’s place of business. The Sales Specialist will collaborate closely with the Delivery Services Engagement team that works with providers, to identify provider related issues, address and resolve these issues as well promote Healthfirst to ensure visibility and increase market share. The Sales Specialist will also be responsible for driving retention efforts so that Healthfirst members maintain health insurance coverage, and ensure there are no gaps in coverage.Duties & Responsibilities:Create, manage and retain membership growth. Work directly with community based organizations, providers, and other sources to obtain self-generated referral and enrollmentsManage your travel and territory efficiently to produce maximum resultsIdentifies potential members and designs a plan to educate the potential members regarding the health benefits and recommends health plans that are tailored to the member’s needs and eligibility. Provide information regarding the particular plan’s features and benefitsLive our mission, our members are our North Star and our mission is guided by their needs and preferences in ensuring a superior experience and access to the highest quality healthcare when and where they need itFor existing members, will review current benefits to determine the most appropriate planWork collaboratively within a team to identify and develop business, including lead generation to create enrollment sources and referral channelsHas discretion as to where solicitation shall be performed within the Healthfirst service areaEstablish and maintain relationships with local community organizations to promote Healthfirst benefits within the communityDetermine and recommend (and/or partner on) appropriate events within the territory to Community Engagement in order to organize events within the territory, including but not limited to health fairs, holiday-themed events,  provider sponsored events as well as health-related theme eventsPartner with DSE for scheduling face to face meetings with Hospitals, IPA’s, and community providers to identify issues and ensure plan visibility. Inform DSE of claim/rate related issues and  follow up with the resultsEngage and educate providers in the territory regarding Healthfirst plansCreate and present health plan seminars on a monthly basis to provider offices and community-based organizationsAdvance Healthfirst market penetration in strategic territories through superior customer service focused in a territory, which will help optimize provider and member satisfactionMaintain a disenrollment rate that is deemed acceptable by HealthfirstStrictly adheres to all CMS and Healthfirst marketing guidelinesMinimum Qualifications:High School Diploma/GED equivalentNew York State Life Accident (optional) & Health License (Mandatory)Experience in selling Medicare Advantage  Experience working with provider network/hospitalBilingual-English and one or more of the following: Spanish, Cantonese, Mandarin, Fukenese, Arabic, Creole, French, BengaliValid Driver's License and access to personal vehicleDemonstrable MS Excel or other spreadsheet software (e.g. Lotus) skills: ability to create and use Excel reports to manage information by using features such as search/find, sort/filter, formatting, inserting columns/rows/field, creating additional worksheets/tabs, formulas, and creating pivot tablesPreferred Qualifications:Associate’s Degree from an accredited institutionExperience in selling Dual Eligible productsAccount management experienceMedicaid and/or Medicare managed care experienceExcellent communication & interpersonal skills (Oral & Written)WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.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 Healthfirst Management Services will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with Healthfirst Management Services.EEO Law Poster and Supplement
Healthfirst Lake Mary, FL
Job Description Description The Operations Specialist is a resource with in-depth account knowledge and is responsible for strengthening provider engagement and enhancing quality. This role will develop effective provider relationships that enhance Health first’s reputation as a “trusted partner” and supports administrative ease.Duties & Responsibilities:Will be the primary point of contact for all delegated entities with regards to on-boarding/credentialing providers. Responsible for the resolution of all issues, including those identified by the provider, and those identified internally that impact the physician.Schedules regular meetings with assigned delegated entities to identify and trouble shoot issues. Trains/educates entities on site regarding the on-boarding delegated process.Responsible for investigations to ensure online Provider directory is updated and accurate. Makes all changes necessary to ensure the directory is at all times accurate.Configures new Provider loads, updates and terminations.  Provides assistance and guidance with large ad-hoc data entry projects in MHS.Performs quarterly roster reconciliations to ensure that the health plan directory is current, accurate and adheres to department guidelines, regulations, and government laws. Tasked with making required changes to ensure directory is compliant.Designated to receive and review provider credentialing applications. Coordinates with hospital/clinic, medical staff, and practitioners to ensure privileging process is timely completed. Determines whether additional documentation, verification, references, and/or applications are needed.Receives, reviews and submits provider contracts.Coordinates with Delivery System Engagement staff to finalize provider applications and contracts.  Responsible for all follow-up so that timely approval occurs.Reports to Team Lead.Additional duties as assigned.Minimum Qualifications:Associate's Degree or equivalent work experienceFamiliarity with Credentialing and Provider rostersUnderstanding Network ManagementExperience working as a liaison with providers and internal support groupsExperience meeting deadlines under time sensitive constraintsExperience adapting to last minute project requestsExperience working independently with minimal supervisionAbility to communicate effectively with providers and internal staff membersDemonstrated willingness to be flexible and adaptable to changing prioritiesTime management skills with ability to manage multiple tasksComputer proficient  including Excel experience being able to create and/or utilize V- lookups, pivot tables, formulas, manipulating data and creating reportsOral and written communication skillsCritical thinking skillsPreferred Qualifications:Bachelor’s degree or aboveExperience with SharePoint, MHS, DocuSign and CRM softwareWE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.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 Healthfirst Management Services will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with Healthfirst Management Services.EEO Law Poster and Supplement
Healthfirst Lake Mary, FL
Job Description Description The Operations Strategic Data Analyst embraces complex, disparate data sets and leading technologies – including Amazon Web Services, Redshift, Alteryx, and Tableau – to design data models, craft scoring methodologies and develop algorithms that inform the leaders of our business on our performance. This individual will be working directly on Healthfirst strategic initiatives to identify solutions that have visibility at the highest levels of the company.Duties & Responsibilities: Operate with intellectual curiosity and critically assess existing processes and procedures to identify opportunities for improvementDevelop complex analyses requiring the integration of multiple data sources, evaluation of data quality, and standardization of data to consistent format/structureCreate advanced queries and reports that extract data to support business teams’ needs, including working with nesting tables and temp tables and writing multiple conditions against varying data sets)Summarize and present data outcomes, recommendations, and methodology to analytics leadership, department leadership, and enterprise stakeholdersLearn, adopt and leverage leading analytical tools and technologies to further the maturity of departmental analytics at-large which may include the development of procedures in Amazon Redshift, workflows in Alteryx, or other solutions as requiredHold oneself accountable for the accuracy, completeness, quality, and relevance of deliverables in order to own responsibility for work product and consider these factors in the end-to-end analytical process, from data gathering to analysis to formatting and presentationEmploy best practices in documentation, coding style and comments to facilitate persistence, re-usability, and scalability of your solutionsDocument and escalate data issues as appropriateExhibit collaborative attitude, willingness to work with others on data projects that included working team(s) made of cross departmental/interdisciplinary usersAdditional duties as assignedMinimum Qualifications:Bachelor’s degree from an accredited institution or equivalent relevant work experienceWorking experience exhibiting strong critical thinking and analytical skillsAdvanced MS Excel skills that include creating pivot tables, macros, utilizing v/h lookups and/or VBAFamiliarity with writing SQL (and/or SAS) queries for analyzing data and establishing business rules and requirementsFamiliarity with relational database structures, theories, principles and practicesFamiliarity with data models and/or data modellingAbility to understand the data life-cycle within the organization and its impact on the businessExperience working in a team-oriented, collaborative environmentAbility to communicate effectively verbally and in writing while demonstrating good grammar, spelling and punctuation skillsWork experience requiring meticulous attention to detailPreferred Qualifications: Degree in Mathematics, Computer Science, Data Sciences, Engineering, Business Analytics, Informatics, or similar concentrationExperience working with SQL in a professional environmentExperience with Alteryx, Tableau, Amazon Redshift, QlikView, or other similar tools/platformsFamiliarity with statistical principles, such as standard deviations, normal distributions, and regressionsFamiliarity with Python and/or RFamiliarity with healthcare dataBalances working independently with an understanding of when to escalate with questions/issuesAbility to work effectively with both business and technical stakeholdersCompliance & Regulatory Responsibilities: N/ALicense/Certification: N/AWE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.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 Healthfirst Management Services will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with Healthfirst Management Services.EEO Law Poster and Supplement
Healthfirst New York, NY
Job Description Description The Pediatric Care Manager plans and manages pediatric medical and/or behavioral care with members and their beneficiaries across the continuum of care. The Care Manager is assigned to a specific product line such as PHSP, Child Health Plus, etc.The Care Manager is responsible for applying care management principles when engaging members and health care team members through coordination of health care services.Adhere to standards of care for children including but not limited to developmentally disabled, medically fragile and foster care populationsDevelops a member centric plan of care through collaboration with member (as age appropriate), family, appointed guardian and the multi-disciplinary health care team (pediatricians, specialists, health homes, school or facility social workers and home or community-based service providers) to maximize the pediatric member’s functional capacity through integrated collaborations.Documents all encounters with pediatric members, guardians, legal representatives, providers and vendors in the appropriate system in accordance with internal and established documentation procedures; follows up as needed; and updates plan of care based on member needs and goals, as appropriate.Conducts assessments telephonically to identify barriers and opportunities for intervention.Evaluates service authorizations and advocates to ensure alignment and execution of the member’s care and physician treatment plan.Educates beneficiaries on available health care services within their coverage plan empowering self-management.Assists in identifying opportunities for alternative care options based on member needs and assessments and coordinates referrals to assist in goal achievement.Occasional overtime as necessary.Additional duties as assigned.Minimum Qualifications:NYS RN.1 year of pediatric clinical field experience, families and child serving systems, including child welfare and/or medically fragile/developmentally disable populations.Proficient with simultaneously navigating the Internet and multi-tasking with multiple electronic documentation systemsAbility to collaborate with multiple stakeholders to secure appropriate careStrong interpersonal and assessment skills, especially the ability to related well with children, their families and community care providers, along with demonstrated ability to handle rapidly changing crisis situations.Preferred Qualifications:Fluency in Spanish, Korean, Mandarin, or Cantonese.Knowledge and experience with the current community health practices for the medically &/or emotionally fragile pediatric population.Experience managing member information in a shared network environment using paperless database modules and archival systems.Relevant work experience as a Care ManagerDemonstrated ability to manage large caseloads and effectively work in a fast-paced environmentExperience using Microsoft Office, SharePoint, TruCare & Interaction systems.WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.Minimum Qualifications:NYS RN orLCSW, LMSW, LMFT, LMHC, LPC, licensed psychologist (any state) Preferred Qualifications:Strong interpersonal and assessment skills, especially the ability to relate well with seniors, their families, and community care providers, along with demonstrated ability to handle rapidly changing crisis situations.Fluency in Spanish, Korean, Mandarin, or Cantonese.Knowledge and experience with the current community health practices for the frail adult population and cognitive impaired seniors.Knowledge of InterQual and LOCADTR.Experience managing member information in a shared network environment using paperless database modules and archival systems.Experience and knowledge of the relevant product lineRelevant work experience preferably as a Care ManagerDemonstrated ability to manage large caseloads and effectively work in a fast-paced environmentProficient with simultaneously navigating the Internet and multi-tasking with multiple electronic documentation systemsExperience using Microsoft Excel with the ability to edit, search, sort/filter and other Microsoft and PHI systemsWE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.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 Healthfirst Management Services will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with Healthfirst Management Services.EEO Law Poster and Supplement