Windsong Radiology Remote jobs - 37 jobs

The Senior Manager, Clinical Utilization Management (UM) Operations is responsible for the strategic and operational leadership oversight of all utilization management activities, ensuring effective, compliant, and high-quality service delivery. This role oversees a team of people leaders who manage clinicians and coordinators responsible for medical necessity review, service authorization, care coordination activities, and other related UM functions. The Senior Manager ensures compliance with all state and federal regulations, contractual obligations, and organizational policies while driving operational excellence, clinical quality, and member-centered outcomes. Duties/Responsibilities: · Provide strategic oversight and operational management for all utilization management functions, including prior authorization, concurrent review, and service requests · Lead, coach, and develop UM managers overseeing interdisciplinary teams of registered nurses, social workers, clinicians, and coordinators · Ensure UM operations meet regulatory requirements set forth by CMS, New York State Department of Health (DOH), and other oversight entities · Establish, monitor, and report on key performance indicators (KPIs), productivity, and quality metrics to ensure compliance and optimal performance · Partner with Clinical Operations, Quality, Compliance, and Provider Relations to ensure alignment and effective communication across departments · Utilize data analytics and reporting tools to identify trends, drive process improvements, and optimize resource allocation · Lead readiness efforts for audits, performance improvement plans, and corrective actions related to utilization management · Foster a culture of accountability, professional development, and continuous improvement across all levels of the team · Serve as a subject matter expert and escalation point for complex or high-impact cases requiring clinical and operational judgment · Support system implementations and technology enhancements to improve automation, reporting, and member/provider experience · Ensure the department maintains timely and accurate completion of service authorizations and reviews in alignment with turnaround time standards · Additional duties as assigned Minimum Qualifications: · Bachelor's degree in Nursing, Healthcare Administration, or a related field from an accredited institution or equivalent work experience · NYS RN · Demonstrated understanding of UM regulatory requirements, clinical review process, and managed care operations · Leadership experience in managing, coaching and developing multidisciplinary clinical teams · Strong analytical, organizational, and problem-solving skills · Work experience demonstrating written and verbal communication skills with the ability to influence and collaborate across functions · Demonstrated success driving high performance and quality outcomes in a fast-paced, regulated environment Preferred Qualifications: · Prior experience leading a team of people leaders · Work experience using Milliman Care Guidelines (MCG) criteria and other state-specific authorization requirements. · Ability to interpret and operationalize regulatory updates and guidance from DOH and CMS · Experience working and/or managing in a virtual environment · Understanding of health plans such as Medicare, Medicaid and/or Managed Long-Term Care Plan (MLTCP) · Experience working as a case manager for a long-term care programs such as PACE, MAP or MLTC · Strong understanding of value-based care principles and their application to MLTC populations · Experience accessing and maintaining patient health information (PHI) electronically in a shared network · Strong computer skills, including, but not limited to word processing, spreadsheets, and databases WE ARE AN EQUAL OPPORTUNITY EMPLOYER. HF Management Services, LLC complies with all applicable laws and regulations. Applicants and employees are considered for positions and are evaluated without regard to race, color, creed, religion, sex, national origin, sexual orientation, pregnancy, age, disability, genetic information, domestic violence victim status, gender and/or gender identity or expression, military status, veteran status, citizenship or immigration status, height and weight, familial status, marital status, or unemployment status, as well as any other legally protected basis. HF Management Services, LLC shall not discriminate against any disabled employee or applicant in regard to any position for which the employee or applicant is otherwise qualified. If you have a disability under the Americans with Disability Act or a similar law and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to *********************** or calling ************ . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within HF Management Services, LLC will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with HF Management Services, LLC. Know Your Rights All hiring and recruitment at Healthfirst is transacted with a valid “@healthfirst.org” email address only or from a recruitment firm representing our Company. Any recruitment firm representing Healthfirst will readily provide you with the name and contact information of the recruiting professional representing the opportunity you are inquiring about. If you receive a communication from a sender whose domain is not @healthfirst.org, or not one of our recruitment partners, please be aware that those communications are not coming from or authorized by Healthfirst. Healthfirst will never ask you for money during the recruitment or onboarding process. Hiring Range*: Greater New York City Area (NY, NJ, CT residents): $119,900 - $183,430 All Other Locations (within approved locations): $102,600 - $156,655 As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision. In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live. *The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.

The Medical Record Coordinator is responsible for performing quality checks on automated reports, received scans, and guaranteeing electronic filing for assigned products and the corresponding members. The Medical Record Coordinator collaborates with multiple departments to obtain and confirm necessary documents are in place and properly set-up in the Electronic Medical System (EMS) database. Performs quality checks to maintain the integrity of events and criteria for reporting purposes. Processes members' electronic documents, proof of data for inaccuracies, and any other missing information. Resolves discrepancies identified using standard procedures and/or returning incomplete documents to their respective departments for correction and resolution. Responds and coordinates field assignments for Interpreters by checking availability and assigning staff as appropriate taking location into consideration. Facilitates manual mailings for other departments. Move existing members, auto-enrollees and dis-enrollments to and from the appropriate line of business lists in the centralized NY State Uniform Assessment System (UAS) for Integrated Products. Additional duties as assigned. Minimum Qualifications: HS diploma/GED Preferred Qualifications: Ability to prioritize and follow through on assigned tasks. Proficiency in navigating the Internet. Ability to work with multiple electronic documentation systems simultaneously. Ability to troubleshoot or explain basic hardware and software errors and work with a Technician remotely to perform step-by-step repairs. Work experience with an electronic patient health information (PHI) database (medical records database). Microsoft Excel skills including edit, search, sort/filter, format using already created pivot tables to locate information. Data entry/database management experience with Microsoft Excel and other systems/ applications. Attention to detail performing quality checks and proofreading. Work experience in a healthcare environment. Knowledge of Medicare, Medicaid, or managed care and medical terminology. WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability 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 *********************** or calling ************ . 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 All hiring and recruitment at Healthfirst is transacted with a valid “@healthfirst.org” email address only or from a recruitment firm representing our Company. Any recruitment firm representing Healthfirst will readily provide you with the name and contact information of the recruiting professional representing the opportunity you are inquiring about. If you receive a communication from a sender whose domain is ********************, or not one of our recruitment partners, please be aware that those communications are not coming from or authorized by Healthfirst. Healthfirst will never ask you for money during the recruitment or onboarding process. Hiring Range*: Greater New York City Area (NY, NJ, CT residents): $39,208 - $52,000 All Other Locations (within approved locations): $34,091 - $49,920 As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision. In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live. *The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.

The Program Coordinator, Reward Card Program in Clinical Quality is responsible for supporting Healthfirst initiatives and regulatory requirements related to Member Rewards and Incentives, HEDIS Quality Improvement, Medicare Stars and Member Satisfaction. This position is both internal (EDS, Marketing, etc.) and external (Members, Provider, Vendor) facing.Duties & Responsibilities: Verifies reward requests based on required preventive services appropriate for the member's age, gender and other accepted demographics as outlined via the Member Reward Card Program Guidelines, HEDIS/QARR Technical Specifications, and CMS/DOH guidelines Conducts member and provider outreach to inform on reward guidance and status using multiple internal systems and applications Collaborates with internal and external teams to track and document program requirements and implementation status Documents, communicates and presents technical improvement findings and recommendations in all systems supporting Member Rewards Program Provides support in creating, editing and communicating member and provider material updates Additional duties as necessary Minimum Qualifications: High School/GED Diploma from an accredited institution Basic knowledge of MS Word, Excel, Access, and Outlook Strong organizational skills Good communication (verbal and written) and interpersonal skills Flexibility, reliability, and easily adaptable to any work assignments or new computer applications Competent in managing responsibilities in a high-volume and fast-paced environment Ability to resolve member issues with patience and courtesy Preferred Qualifications: Associate's degree from an accredited institution + 2 Years Work Experience. Experience processing reward card requests highly preferred. Bilingual in English and one or more language(s): Spanish, Mandarin, Cantonese may be required based on business needs Familiarity with some medical terminology. Experience addressing member inquiries in a managed care environment. Knowledge of CPT and ICD-9 codes. Compliance & Regulatory Responsibilities: Noted above License/Certification: N/A WE ARE AN EQUAL OPPORTUNITY EMPLOYER. HF Management Services, LLC complies with all applicable laws and regulations. Applicants and employees are considered for positions and are evaluated without regard to race, color, creed, religion, sex, national origin, sexual orientation, pregnancy, age, disability, genetic information, domestic violence victim status, gender and/or gender identity or expression, military status, veteran status, citizenship or immigration status, height and weight, familial status, marital status, or unemployment status, as well as any other legally protected basis. HF Management Services, LLC shall not discriminate against any disabled employee or applicant in regard to any position for which the employee or applicant is otherwise qualified. If you have a disability under the Americans with Disability Act or a similar law and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to *********************** or calling ************ . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within HF Management Services, LLC will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with HF Management Services, LLC. Know Your Rights All hiring and recruitment at Healthfirst is transacted with a valid “@healthfirst.org” email address only or from a recruitment firm representing our Company. Any recruitment firm representing Healthfirst will readily provide you with the name and contact information of the recruiting professional representing the opportunity you are inquiring about. If you receive a communication from a sender whose domain is ********************, or not one of our recruitment partners, please be aware that those communications are not coming from or authorized by Healthfirst. Healthfirst will never ask you for money during the recruitment or onboarding process. Hiring Range*: Greater New York City Area (NY, NJ, CT residents): $40,200 - $54,570 All Other Locations (within approved locations): $34,900 - $52,000 As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision. In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live. *The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.

The Coding Educator is responsible for overseeing and educating providers on the proper use of diagnosis coding to ensure CMS and ICD10 CM guidelines are followed to substantiate the Risk Adjustment HCCs that are reported by providers. Responsible for auditing clinical documentation encounters to validate Risk Adjustment and HCCs Responsible for managing and responding to provider inquiries via the coding hotline as well. Trains clinical providers on coding guidelines, ensuring compliance around clinical documentation, coding guidelines. Using AMA Coding guidelines, CMS coding regulations, ICD10 coding rules and coding industry standards. Preparation and creation of PowerPoint presentations for department meetings. Creation of PDF Job Aid to describe coding rules for all specialties. Responsible for CDI (Clinical Documentation Improvement) guidelines. Performs charge audits through review of chart notes and assigns correct procedure and diagnosis codes. Review and analyze new ICD10 coding guidelines, new ICD10 changes and create education material every year around said changes Proficient on coding guidelines on all the specialties. Reviews audit results to identify and analyze trends, recommend and implement corrective actions. Regular site meetings with all our providers to provide coding and clinical documentation improvement to improve coding accuracy Manage and respond timely to provider inquiries via the coding hotline to ensure providers have the appropriate resources to handle coding questions. Consistently and accurately audits complex coding records for inpatient and outpatient - hospital and professional. Creates clear and concise audit reports. Reports non-compliance issues detected through auditing and monitoring. Establishes, implements, and maintains a formalized review process that incorporates regular audits (provider, coding and documentation adequacy) and coordinates ongoing monitoring with education to provider. Conducts trend analyses to identify patterns, variations in coding practices and case-mix index, including areas of risk and comparing coding profiles with national norms. Develops and coordinates educational and training programs regarding elements of the coding compliance program, such as appropriate documentation, accurate coding, data compatibility, consistency and monitoring for compliance to improve the quality of clinical data supported. Provides feedback and focused educational programs based on the results of auditing and monitoring activities to affected providers and hospitals Initiates corrective action plans and reports results of follow-up audits to Coding Manager and AVP. Maintains statistics on coding accuracy and provides monthly summaries of coding audit results Acts as a resource on coding issues and questions to ensure accurate coding for appropriate Risk Adjustment data capture for inpatient and outpatient. Demonstrates up-to-date knowledge of healthcare regulatory, coding mandates and OIG work plan. Analyze audits and RA findings. Maintains records of, files, education, presentations, etc. concerning all external physician audits. Minimum Requirements · Minimum five years' experience coding education in a hospital, physician, or insurance environment · Minimum five years' experience coding SOAP notes for different specialties · High School diploma or GED. · Certified Coding Profession certification: CPC and CRC (If no CRC, then it must be obtained within the first 6 months of employment) Preferred Requirements · Bachelor's Degree Preferred · Certified Coding Profession certification: CPMA, CDEO, CCS, CCS-P, CDIP, RHIA, RHIT WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability 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 *********************** or calling ************ . 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 All hiring and recruitment at Healthfirst is transacted with a valid “@healthfirst.org” email address only or from a recruitment firm representing our Company. Any recruitment firm representing Healthfirst will readily provide you with the name and contact information of the recruiting professional representing the opportunity you are inquiring about. If you receive a communication from a sender whose domain is not @healthfirst.org, or not one of our recruitment partners, please be aware that those communications are not coming from or authorized by Healthfirst. Healthfirst will never ask you for money during the recruitment or onboarding process. Hiring Range*: Greater New York City Area (NY, NJ, CT residents): $81,100 - $117,470 All Other Locations (within approved locations): $71,600 - $106,505 As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision. In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live. *The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.

The Quality Assurance Financial Auditor II is responsible for performing Quality Assurance Audits of financial processes completed by internal employees and outsources vendors to ensure compliance with policies, procedures, and quality standards to mitigate financial risk. You will investigate, audit, conduct root cause analysis, handle processing of determinations, and track/trend findings under minimal supervision. This position is 100% Remote. Scope of Responsibilities: Conduct moderately complex to complex quality audits of provider claims, pre-payments and post-payments including high-dollar and specialized claims across multiple lines of business, claim types and products. Audit the work of more junior auditors and identify opportunities for coaching and/or training. Identify and communicate issues identified through audits and recommended solutions relevant to business operations. Assist management in preparing departmental reports policies and procedures. Mentor and coach Financial and/or Operations QA auditors. Participate as a Subject Matter Expert on various process improvement projects designed to meet departmental and operational needs. Assist with performing User Acceptance Testing (UAT) on system enhancements or corporate projects in partnership with Business Operations Analyze errors and determine root causes for appropriate classification. Record/track quality assessment scores and provide feedback to reduce errors and improve processes and performance to ensure the quality of the network. Review and investigate claims and encounters for medical, facility, pharmacy, dental and vision services including contractual provisions, authorizations and Healthfirst policy and procedure. Prepare written reports concerning investigation activities and present results of investigations to senior staff. Complete subsequent auditing and handling of specific claims and appeal requests including processing where applicable, tracking, documenting, reporting and dispersal of findings and recommendations. Review the accuracy and efficiency of existing training materials. Minimum Qualifications: Audit experience with the investigation, determination and reporting of financial processes. Work experience in Microsoft Office suite of applications including advanced Excel (formatting formulas, managing data, filtering results), Word (creating and editing documents), PowerPoint (creating and editing presentations) Experience conducting root cause analysis in an auditing capacity. Experience conducting analytical work and providing creative ideas for problem solving. Work experience requires written and verbal communication that is clear, concise, grammatically correct, and professional. Experience handling confidential information. Associate degree from an accredited institution. Preferred Qualifications: Bachelor's degree from an accredited institution Audit experience with the investigation, determination and reporting of financial processes specifically around Healthcare Claims Adjudication and Claims Processing Ability and willingness to handle increasing workload and responsibility Willingness and ability to learn and evaluate new information, both technical and procedural ICD10 certification Basic foundation of SQL, Tableau, and SharePoint Knowledge of at least two or more lines of business such as NY Medicare, Medicaid, Family Health Plus, Child Health Plus WE ARE AN EQUAL OPPORTUNITY EMPLOYER. HF Management Services, LLC complies with all applicable laws and regulations. Applicants and employees are considered for positions and are evaluated without regard to race, color, creed, religion, sex, national origin, sexual orientation, pregnancy, age, disability, genetic information, domestic violence victim status, gender and/or gender identity or expression, military status, veteran status, citizenship or immigration status, height and weight, familial status, marital status, or unemployment status, as well as any other legally protected basis. HF Management Services, LLC shall not discriminate against any disabled employee or applicant in regard to any position for which the employee or applicant is otherwise qualified. If you have a disability under the Americans with Disability Act or a similar law and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to *********************** or calling ************ . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within HF Management Services, LLC will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with HF Management Services, LLC. Know Your Rights All hiring and recruitment at Healthfirst is transacted with a valid “@healthfirst.org” email address only or from a recruitment firm representing our Company. Any recruitment firm representing Healthfirst will readily provide you with the name and contact information of the recruiting professional representing the opportunity you are inquiring about. If you receive a communication from a sender whose domain is ********************, or not one of our recruitment partners, please be aware that those communications are not coming from or authorized by Healthfirst. Healthfirst will never ask you for money during the recruitment or onboarding process. Hiring Range*: Greater New York City Area (NY, NJ, CT residents): $68,900 - $99,620 All Other Locations (within approved locations): $61,300 - $89,440 As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision. In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live. *The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.

The Performance Support Specialist will be responsible for providing assistance in resolving complaint issues escalated by the representatives. This role is required to pull non-urgent complaint reporting through various systems on a daily basis, review each matter and reach out to the member in order to provide determinations while maintain a tracking system for any and all incoming complaint issues. Duties & Responsibilities: Assist in resolving customer complaints escalated by internal and external business partners as needed. Assist in reviewing and modifying Physician capitation reports. Assist in resolving member issues who called in multiple times with the same issues. Assist in responding and resolving escalated inquiries from other departments and external contacts. Make recommendations on process improvements. Build sustainable relationships of trust through open and interactive communication with internal and external customers. Able to properly follow procedures based on issues and documents received Make recommendations to management concerning staff performance. Make recommendations on process improvement. Maintain open exchange of information with external and internal customers. Required to multi-task, prioritize and manage time effectively. Timely filing of complaints. Conduct outreaches as required. Attend meetings as business requires. Additional duties as assigned. Minimum Qualifications: High School Diploma or GED from an accredited institution Healthcare industry experience Experience working in customer service Excellent telephone & customer service skills Experience working in clerical or administrative capacity Experience meeting strict deadlines Proficient in Microsoft suite of applications including Word, Power point, Outlook and Excel. Preferred Qualifications: Associate degree from an accredited school Conflict Resolution Experience Experience handling complex situations and/or projects Experience in developing and coaching of staff Compliance & Regulatory Responsibilities: NA License/Certification: NA WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability 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 *********************** or calling ************ . 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 All hiring and recruitment at Healthfirst is transacted with a valid “@healthfirst.org” email address only or from a recruitment firm representing our Company. Any recruitment firm representing Healthfirst will readily provide you with the name and contact information of the recruiting professional representing the opportunity you are inquiring about. If you receive a communication from a sender whose domain is ********************, or not one of our recruitment partners, please be aware that those communications are not coming from or authorized by Healthfirst. Healthfirst will never ask you for money during the recruitment or onboarding process. Hiring Range*: Greater New York City Area (NY, NJ, CT residents): $47,403 - $62,400 All Other Locations (within approved locations): $41,101 - $60,320 As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision. In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live. *The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.

As part of Healthfirst's comprehensive care management approach, we have field-based staff who visit our vulnerable members to assess and address their needs. The FCC Team Lead (FCC TL) is responsible for leadership and supervision of the Field Care Coordinators (FCC). Each Team Lead will supervise a team of FCCs assigned to a specific geography, and ensure the FCCs conduct their home care management visits according to departmental policies. The FCC TL role is hybrid and will be a mix of remote and in-field supervision of a field team. Supervises, evaluates, and coordinates daily team operations and responsibilities to ensure that departmental productivity goals are met in regards to quality, timeliness, accuracy, and consistency Allocates, monitors, and assigns resources while delegating and monitoring workloads Implements and supports continuous process improvement and quality initiatives Provides in-field support to the FCC staff, including supervision, coaching and training Exercises judgment within defined procedures and policies to determine appropriate actions and administers departmental policies Develops and monitors team goals; provides ongoing feedback and coaching; conducts annual performance reviews; leads by example; and ensures an atmosphere of open communication, teamwork, and empowerment to make informed decisions Assists leadership in directing, training, and developing team members by embodying the Trailblazer mindset and leading others by example Builds and develops relevant business relationships, critically thinks about departmental problems, and makes informed recommendations as to how to resolve issues Additional duties as assigned Minimum Qualifications: High School Diploma or GED Bilingual Spanish skills - Full Fluency required Demonstrated professionalism with experience in direct or indirect leadership of people or projects Experience in a role requiring independent-critical thinking, time management, problem solving and achieving goals Ability to travel to assigned geography (assignments will be in the downstate New York area which includes the 5 boroughs, Long Island, Orange County, and Westchester) Work experience requiring effective communication verbally and in writing while demonstrating good grammar, spelling, and punctuation skills Proficient computer skills experience, including proficiency with Microsoft Outlook, Word and Excel Preferred Qualifications: Associate's or Bachelor's degree Prior training experience Experience managing field teams Prior leadership skills along with ability to develop, direct, and support a team Adept at planning, organizing, and executing strategies Ability to build and enhance team productivity to achieve team goals WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability 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 *********************** or calling ************ . 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 All hiring and recruitment at Healthfirst is transacted with a valid “@healthfirst.org” email address only or from a recruitment firm representing our Company. Any recruitment firm representing Healthfirst will readily provide you with the name and contact information of the recruiting professional representing the opportunity you are inquiring about. If you receive a communication from a sender whose domain is not @healthfirst.org, or not one of our recruitment partners, please be aware that those communications are not coming from or authorized by Healthfirst. Healthfirst will never ask you for money during the recruitment or onboarding process. Hiring Range*: Greater New York City Area (NY, NJ, CT residents): $67,205 - $95,680 All Other Locations (within approved locations): $59,800 - $87,360 As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision. In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live. *The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.

The Care Manager plans and manages behavioral and/or physical care with members and works collaboratively with them, their supports, providers, and health care team members. The Care Manager is responsible for applying care management principles when engaging members and addressing coordination of their health care services to provide an excellent member experience, address barriers, and improve their health outcomes. The Care Manager is assigned to a specific product line such as CompleteCare, SNP, Medicaid/Medicare, PHSP, HARP, etc. Duties and Responsibilities: Advocates, informs, and educates beneficiaries on services, self-management techniques, and health benefits. Conducts assessments to identify barriers and opportunities for intervention. Develops care plans that align with the physician's treatment plans and recommends interventions that align with proposed goals. Generates referrals to providers, community-based resources, and appropriate services and other resources to assist in goal achievement and maintenance of successful health outcomes. Liaise between service providers such as doctors, social workers, discharge planners, and community-based service providers to ensure care is coordinated and care needs are adequately addressed. Coordinates and facilitates with the multi-disciplinary health care team as necessary to ensure care plan goals and treatment is person-centered and maximizes member health outcomes. Assists in identifying opportunities for alternative care options based on member needs and assessments. Evaluates service authorizations to ensure alignment and execution of the member's care and physician treatment plan. Contributes to corporate goals through ongoing execution of member care plans and member goal achievement. Documents all encounters with providers, members, and vendors in the appropriate system in accordance with internal and established documentation procedures; follows up as needed; and updates care plans based on member needs, as appropriate. Occasional overtime as necessary. Additional duties as assigned. Minimum Qualifications: For Medical Care Management: NYS RN or LCSW or LMSW (any state) For PEDS positions only: 1 year of pediatric clinical field experience and/or experience with families and child serving systems, including child welfare and/or medically fragile/developmentally disabled populations For Behavioral Health (BH) Care Management: NYS RN or LCSW, LMSW, LMFT, LMHC, LPC, licensed psychologist (any state) 3 years of work experience in a mental/behavioral health or addictions setting For BH PEDS positions only: 1 year of pediatric clinical field experience and/or experience with families and child serving systems, including child welfare and/or medically fragile/developmentally disabled populations 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 situations. Fluency in Fujianese Knowledge and experience with the current community health practices for the frail adult population and cognitive impaired seniors. Experience managing member information in a shared network environment using paperless database modules and archival systems. Experience and knowledge of the relevant product line Relevant work experience preferably as a Care Manager Demonstrated ability to manage large caseloads and effectively work in a fast-paced environment Proficient with simultaneously navigating the Internet and multi-tasking with multiple electronic documentation systems Experience using Microsoft Excel with the ability to edit, search, sort/filter and other Microsoft and PHI systems WE ARE AN EQUAL OPPORTUNITY EMPLOYER. HF Management Services, LLC complies with all applicable laws and regulations. Applicants and employees are considered for positions and are evaluated without regard to race, color, creed, religion, sex, national origin, sexual orientation, pregnancy, age, disability, genetic information, domestic violence victim status, gender and/or gender identity or expression, military status, veteran status, citizenship or immigration status, height and weight, familial status, marital status, or unemployment status, as well as any other legally protected basis. HF Management Services, LLC shall not discriminate against any disabled employee or applicant in regard to any position for which the employee or applicant is otherwise qualified. If you have a disability under the Americans with Disability Act or a similar law and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to *********************** or calling ************ . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within HF Management Services, LLC will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with HF Management Services, LLC. Know Your Rights All hiring and recruitment at Healthfirst is transacted with a valid “@healthfirst.org” email address only or from a recruitment firm representing our Company. Any recruitment firm representing Healthfirst will readily provide you with the name and contact information of the recruiting professional representing the opportunity you are inquiring about. If you receive a communication from a sender whose domain is ********************, or not one of our recruitment partners, please be aware that those communications are not coming from or authorized by Healthfirst. Healthfirst will never ask you for money during the recruitment or onboarding process. Hiring Range*: Greater New York City Area (NY, NJ, CT residents): $81,099 - $116,480 All Other Locations (within approved locations): $71,594 - $106,080 As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision. In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live. *The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.

The Clinical UM Pharmacist is a dynamic position responsible for the review of prior authorizations for medications requested under the medical benefit. Additionally, the Clinical UM Pharmacist is responsible for developing clinical criteria, medical policies for provider administered medications, review of monthly report for quality assurance, and staying current with literature, evidence-based medicine, and trends in medicine. The Clinical Pharmacist works directly with prescribing physicians and Medical Directors to discuss clinical rationale for review decisions. Duties & Responsibilities: Monitor and review prior authorization requests for medications Calculate appropriate billable units based on dosing, indication, weight, BMI and other clinical considerations Develop clinical criteria and medical policies for the review of medications Ensure all clinical criteria is in compliance with Center of Medicare and Medicaid Services (CMS) and the New York State Department of Health (NYSDOH) Research drug information to maintain drug knowledge and disease state understanding for application to prior authorization reviews Ensure prior authorization reviews are conducted in timeframes set forth by CMS and/or NYSDOH Work across departments as needed to complete Utilization Management reviews Review monthly reports and provide feedback on trends, ideas for efficiency, and innovation Ability to work well in a team environment and be a team player Additional duties as assigned or required Minimum Qualifications: Pharmacy degree from an accredited school of pharmacy Registered Pharmacist with a state license in good standing. Work experience conducting prior authorization reviews Clinical knowledge of pharmaceuticals and disease states in order to conduct prior authorization reviews Work experience requiring written and verbal clinical communication that is clear, concise, grammatically correct, and professional Knowledge of specialty pharmaceuticals and billing practices in the medical and pharmacy benefits Preferred Qualifications: PGY1 Managed Care Residency Knowledge of regulations of the Centers for Medicare and Medicaid Services including but not limited to National and Local Coverage Determinations Demonstrated critical thinking and problem-solving skills Passion for learning, promoting the profession of pharmacy, and interest in growing skills in a dynamic environment with various opportunities Experience leading large and small working meetings PC Skills with Microsoft Outlook, Word, PowerPoint (creating presentations and slides), and Excel (Pivot tables) Compliance & Regulatory Responsibilities: Assists in regulatory and compliance audits for all plans. Ensure all activities are conducted in compliance with regulations. License/Certification: Licensed pharmacist in good standing WE ARE AN EQUAL OPPORTUNITY EMPLOYER. HF Management Services, LLC complies with all applicable laws and regulations. Applicants and employees are considered for positions and are evaluated without regard to race, color, creed, religion, sex, national origin, sexual orientation, pregnancy, age, disability, genetic information, domestic violence victim status, gender and/or gender identity or expression, military status, veteran status, citizenship or immigration status, height and weight, familial status, marital status, or unemployment status, as well as any other legally protected basis. HF Management Services, LLC shall not discriminate against any disabled employee or applicant in regard to any position for which the employee or applicant is otherwise qualified. If you have a disability under the Americans with Disability Act or a similar law and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to *********************** or calling ************ . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within HF Management Services, LLC will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with HF Management Services, LLC. Know Your Rights All hiring and recruitment at Healthfirst is transacted with a valid “@healthfirst.org” email address only or from a recruitment firm representing our Company. Any recruitment firm representing Healthfirst will readily provide you with the name and contact information of the recruiting professional representing the opportunity you are inquiring about. If you receive a communication from a sender whose domain is ********************, or not one of our recruitment partners, please be aware that those communications are not coming from or authorized by Healthfirst. Healthfirst will never ask you for money during the recruitment or onboarding process. Hiring Range*: Greater New York City Area (NY, NJ, CT residents): $103,400 - $149,430 All Other Locations (within approved locations): $88,700 - $131,920 As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision. In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live. *The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. HF Management Services, LLC complies with all applicable laws and regulations. Applicants and employees are considered for positions and are evaluated without regard to race, color, creed, religion, sex, national origin, sexual orientation, pregnancy, age, disability, genetic information, domestic violence victim status, gender and/or gender identity or expression, military status, veteran status, citizenship or immigration status, height and weight, familial status, marital status, or unemployment status, as well as any other legally protected basis. HF Management Services, LLC shall not discriminate against any disabled employee or applicant in regard to any position for which the employee or applicant is otherwise qualified. If you have a disability under the Americans with Disability Act or a similar law and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to *********************** or calling ************ . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within HF Management Services, LLC will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with HF Management Services, LLC. Know Your Rights All hiring and recruitment at Healthfirst is transacted with a valid “@healthfirst.org” email address only or from a recruitment firm representing our Company. Any recruitment firm representing Healthfirst will readily provide you with the name and contact information of the recruiting professional representing the opportunity you are inquiring about. If you receive a communication from a sender whose domain is not @healthfirst.org, or not one of our recruitment partners, please be aware that those communications are not coming from or authorized by Healthfirst. Healthfirst will never ask you for money during the recruitment or onboarding process.

The Clinical Auditor performs audit functions for Healthfirst clinical teams (e.g. Care Management, Reassessment/Clinical Eligibility, Utilization Management, etc.) and delegated vendors and partners [within internal timeframes and deadlines] to determine operational efficiency, adherence to regulatory requirements, and achievement of quality standards. The audits may include but are not limited to listening to Care Manager phone calls; review of Uniform Assessment System (UAS) assessments, care plans, medical authorizations, and supporting documentation ensure compliance with regulatory requirements and internal policy; etc. Duties and Responsibilities: Maintains tracking tools to log audit results including areas of non-compliance and informing what areas of improvement are needed for discussion with management and/or at departmental team meetings Assists with evaluating and analyzing aggregate quality performance data Develops strategies for business performance improvement initiatives. This includes: identifying opportunities for improvement, problem prioritization, and creating performance improvement plans for non-compliant audits and/or reports Assists with creating and revising audit tools to ensure audits and reports are value-added Applies clinical and critical thinking skills to evaluate the quality and effectiveness of case management and/or utilization review decision-making Additional duties as assigned Minimum Qualifications: NYS LPN or RN license. In order to access the Uniform Assessment System (UAS), an unexpired NYS driver's license or NYS ID is required. If residing outside of NYS, the candidate must be able to obtain a NYS ID before commencement of employment. Preferred Qualifications: Relevant previous work experience such as medical records review; claims processing; utilization/case management in a clinical practice or managed care organization; managed care plan products (e.g. Medicaid, Medicare, Commercial) and knowledge of Department of Health (DOH) and Local Department of Social Services and Center for Medicare & Medicaid Services (CMS) regulations pertaining to managed care; nursing experience in an acute, sub-acute or long-term care (LTC) setting or managed long-term care plan (MLTCP, FIDA); Geriatrics, Medical Surgical Nursing, Case Management or Discharge Planning; etc. Experience working with any of the following systems: CareEnhance Clinical Management Software (CCMS), TrueCare, PEGA, Citrix, RightFax, VoIP, Virtual work platforms (VPN), Electronic medical record (EMR) database containing patient health information (PHI), and/or MACESS archival system. Language preferences - Spanish, Russian, French, Creole, Mandarin, Cantonese. Intermediate Microsoft Word, Excel, and Outlook skills Ability to build and maintain positive relationships with cross-functional teams and interact with all levels of management. Time management, critical/creative thinking, project management, communication, and problem-solving skills License or Certification: NYS LPN or RN license. Regulatory or Compliance activities: n/a WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability 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 *********************** or calling ************ . 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 All hiring and recruitment at Healthfirst is transacted with a valid “@healthfirst.org” email address only or from a recruitment firm representing our Company. Any recruitment firm representing Healthfirst will readily provide you with the name and contact information of the recruiting professional representing the opportunity you are inquiring about. If you receive a communication from a sender whose domain is ********************, or not one of our recruitment partners, please be aware that those communications are not coming from or authorized by Healthfirst. Healthfirst will never ask you for money during the recruitment or onboarding process. Hiring Range*: Greater New York City Area (NY, NJ, CT residents): $81,099 - $116,480 All Other Locations (within approved locations): $71,594 - $106,080 As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision. In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live. *The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.

The Healthfirst Credentialing department credentials and re-credentials providers, facilities and vendors; prepares hard-copy directories and reviews network provider data for accuracy and ensures compliance with regulatory requirements and federal and state regulations. Duties/Responsibilities: Credentials providers, facilities, and vendors in accordance to regulations and Healtfirst policy. Prepares presentations for the quarterly credentialing and delegate vendor oversight committee meetings. Facilitates pre-delegation and delegation vendor audits to ensure adherence to contractual arrangements. Prepares hard-copy directories and works with third party vendors for posting online directories. Reviews relevant data to ensure accuracy. Effectively communicates to internal departments and external partners. Identifies and assesses opportunities to improve processes to better ensure regulatory compliance and adherence to state and federal regulations. Raises issues to management and assists in resolution. Additional duties as assigned. Minimum Qualifications: HS diploma/GED Preferred Qualifications: Bachelor's degree Prior relevant experience Time and project management, critical/creative thinking, communication, and problem-solving skills. Intermediate Microsoft software skills include Adobe, Access, Excel, Word, PowerPoint, and Office WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability 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 *********************** or calling ************ . 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 All hiring and recruitment at Healthfirst is transacted with a valid “@healthfirst.org” email address only or from a recruitment firm representing our Company. Any recruitment firm representing Healthfirst will readily provide you with the name and contact information of the recruiting professional representing the opportunity you are inquiring about. If you receive a communication from a sender whose domain is ********************, or not one of our recruitment partners, please be aware that those communications are not coming from or authorized by Healthfirst. Healthfirst will never ask you for money during the recruitment or onboarding process.

Salary Range $50.20 - $78.52 Located in the heart of Washington, we enjoy open skies, snow-capped mountains, and the lakes and rivers of the high desert. We are the proud home of orchards, farms, and small communities. Confluence Health actively supports the communities we serve and their quality of life through our community support program and through our individual efforts as involved community members. Employees of Confluence Health receive a wide range of benefits in addition to compensation. * Medical, Dental & Vision Insurance * Flexible Spending Accounts & Health Saving Accounts * CH Wellness Program * Paid Time Off * Generous Retirement Plans * Life Insurance * Long-Term Disability * Gym Membership Discount * Tuition Reimbursement * Employee Assistance Program * Adoption Assistance * Shift Differential For more information on our Benefits & Perks, click here! Summary * This position does have the ability to be fully remote (must reside in WA, OR, ID, WI, FL, MT, GA, TX, or AZ)) and possess the following skillset: * Strong experience designing, deploying , and managing Citrix Virtual Apps and Desktops (CVAD) environments. * Hands-on experience with profile management in non-persistent VDI environments using Citrix PVS, WEM, FSLogix, and Citrix App Layering. * Knowledge of Active Directory, Group Policy, and networking fundamentals (TCP/IP, DNS, DHCP). * Endpoint management and application packaging/deployment using App-V, SCCM, Intune, Autopilot. Please be sure to call out this experience in your resume if these skills apply to you. This position reports to the IT Engineering Supervisor. Responsible for planning, designing, implementing, and maintaining Enterprise Systems, Application and Endpoint Infrastructure. This includes enterprise compute, storage, backup, virtualization, datacenter, SQL, application deployment, application security, printer management, patch management, Windows Server and Desktop, mobile devices, and virtual desktops. This role is considered an expert in the technical aspects of Enterprise Systems, Application and Endpoint Infrastructure. Makes solid, well thought out, technical recommendations and provides guidance to the IT Engineers. This role is the final escalation for enterprise systems related issue and guidance. Position Reports To: IT - Network Service Manager Essential Functions * Monitors and responds to request and incident tickets assigned to team and provides prompt updates to keep requestor informed, working to resolve all issues in a timely manner. * Creates and maintains Systems, Application and Endpoint documentation and updates documentation to reflect change. * Proactively identifies performance and operational issues using trending activities and reports. * Leads daily operations for the team, providing clarification on priorities and work assignments. * Assists with coordinating technical staff support (internal and external) for escalated problems. * Maintains reporting metrics on activities and completions to leadership though dashboards or other key written updates. Coordinates roadmap updates with team and leadership. * Leads Architectural Review meetings on a rotating basis and participates in Architectural Review to ensure new systems are appropriate for the CH environment. * Working with all engineering disciplines, customers, vendors, and management, the Senior IT Engineer makes recommendations on technology investments to guide strategic planning. * Responsible for the recovery from a disaster or major network outage, leading the delivery of RCA and remediation effort. * Responsible for auditing, identifying, and implementing performance and operational improvements. Oversees Systems Infrastructure, Application Infrastructure and Endpoint device capacity planning, monitoring and reporting. * Responsible for maintaining and updating all network devices. Identifies, evaluates, recommends, new Systems Infrastructure, Application Infrastructure and Endpoint device technologies. * Serves as an escalation point for Network and Security Engineering. * Maintains compliance of all team members for following procedures and documentation, including change management and requirements provided by the organization. * Participates in On-Call rotation and responds in a timely manner as defined by management. * Performs other duties as assigned. Demonstrate standards of behavior and adhere to the Code of Conduct in all aspects of job performance at all times. Qualifications Required: * Bachelor's Degree in Computer Science, Information Technology, other IT related field or equivalent experience. * 7+ years in Information Technology with 5+ years in System or Application Engineering. * Ability to perform in high paced environment, updating and improving documentation as improvements and changes are made. * Team oriented, participating in collaboration on leading best business practices. Organized and can prioritize work with minimal supervision. * Certification: Two certifications from the following VMware Certified Professional (VCP), Citrix Certified Professional (CCP), Azure Database Administrator Associate, Microsoft Certified Endpoint Administrator Associate, Microsoft Certified Endpoint Administrator Associate, Microsoft Azure Administrator Associate or other relevant Engineer Certification. Desired: * Excellent communication, interpersonal, troubleshooting and documentation skills. Ability to effectively present information, respond to questions, and educate diverse groups of people. * Ability to use logical thinking to solve practical problems and interpret instructions for complex oral or written processes. * Ability to read, write, analyze, and interpret general business periodicals, professional journals, technical manuals, and government regulatory guidelines. Ability to learn new technology quickly. * Certification: VMware Certified Advanced Professional (VCAP), Citrix Certified Expert (CCE), Certified Azure Solutions Architect Expert, Certified Power Solution Architect Expert, Microsoft 365 Certified Administrator Expert or other relevant Engineer Certification. Physical/Sensory Demands O = Occasional, represents 1 to 25% or up to 30 minutes in a 2 hour workday. F = Frequent, represents 26 to 50% or up to 1 hour of a 2 hour workday. C = Continuous, represents 51% to 100% or up to 2 hours of a 2 hour workday. Physical/Sensory Demands For This Position: * Walking - O * Sitting/Standing - F * Reaching: Shoulder Height - O * Reaching: Above shoulder height - O * Reaching: Below shoulder height - O * Climbing - O * Pulling/Pushing: 25 pounds or less - O * Pulling/Pushing: 25 pounds to 50 pounds - O * Pulling/Pushing: Over 50 pounds - O * Lifting: 25 pounds or less - O * Lifting: 25 pounds to 50 pounds - O * Lifting: Over 50 pounds - O * Carrying: 25 pounds or less - O * Carrying: 25 pounds to 50 pounds - O * Carrying: Over 50 pounds - O * Crawling/Kneeling - O * Bending/Stooping/Crouching - O * Twisting/Turning - O * Repetitive Movement - F Working Conditions: * This position will work with minimal supervision. The position will require the ability to work flexible hours as needed. This position is generally an office position working at a desk however some time may be spent on site in data centers. Job Classification: * FLSA: Exempt * Hourly/Salary: Salary Physical Exposures For This Position: * Unprotected Heights - Not specified * Heat - Not specified * Cold - Not specified * Mechanical Hazards - Not specified * Hazardous Substances - Not specified * Blood Borne Pathogens Exposure Potential - Not specified * Lighting - Yes * Noise - Not specified * Ionizing/Non-Ionizing Radiation - Not specified * Infectious Diseases - Not specified

The UM Pharmacy Technician is responsible for the intake and review of prior authorization requests for medications requested under the medical benefit. The UM Pharmacy Technician makes approval decisions and denial recommendations based on predetermined clinical criteria. They establish rapport with Provider offices and leverages strong communication and customer service skills when providing updates and delivering decision notifications to members and providers, The UM Pharmacy Technician position is part of multidisciplinary team and works closely with Providers, Pharmacists, and Medical Directors. Duties & Responsibilities: Reviews prior authorization requests and units for medications requested under the medical benefit Assesses provider-submitted clinical information for clinical appropriateness based on predetermined clinical criteria Sends notification to members and providers of authorization decisions via telephone, fax, or mail Ensures prior authorization reviews are conducted within timeframes set forth by CMS and/or NYSDOH Establishes great rapport with Provider offices via telephonic communication Sends request for information sheets to Providers Ensures that patient information is shared appropriately maintaining confidentiality and compliance with federal law and HIPAA regulations Additional duties as necessary Minimum Qualifications: High School Diploma or GED from an accredited institution Either nationally certified Pharmacy Technician in good standing (i.e., PTCB, NHA) or registered or licensed Pharmacy Technician in good standing Experience conducting prior authorization reviews Experience requiring written, verbal, and telephonic communication in English that is clear, concise, grammatically correct, and professional Preferred Qualifications: Strong written and verbal communication skills in Chinese, Spanish, or Russian Demonstrated critical thinking and problem-solving skills Team player with a passion for learning and interest in growing skills in a dynamic environment with various opportunities Knowledge of specialty pharmaceuticals and billing practices in the medical benefit Knowledge of regulations of the Centers for Medicare and Medicaid Services including but not limited to National and Local Coverage Determinations PC Skills with Microsoft Word, PowerPoint (creating presentations and slides), and Excel (Pivot tables). Experience with TruCare Care Management Platform Compliance & Regulatory Responsibilities: Noted above License/Certification: Nationally certified Pharmacy Technician in good standing (i.e., PTCB, NHA) or registered or a licensed Pharmacy Technician in good standing. WE ARE AN EQUAL OPPORTUNITY EMPLOYER. HF Management Services, LLC complies with all applicable laws and regulations. Applicants and employees are considered for positions and are evaluated without regard to race, color, creed, religion, sex, national origin, sexual orientation, pregnancy, age, disability, genetic information, domestic violence victim status, gender and/or gender identity or expression, military status, veteran status, citizenship or immigration status, height and weight, familial status, marital status, or unemployment status, as well as any other legally protected basis. HF Management Services, LLC shall not discriminate against any disabled employee or applicant in regard to any position for which the employee or applicant is otherwise qualified. If you have a disability under the Americans with Disability Act or a similar law and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to *********************** or calling ************ . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within HF Management Services, LLC will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with HF Management Services, LLC. Know Your Rights All hiring and recruitment at Healthfirst is transacted with a valid “@healthfirst.org” email address only or from a recruitment firm representing our Company. Any recruitment firm representing Healthfirst will readily provide you with the name and contact information of the recruiting professional representing the opportunity you are inquiring about. If you receive a communication from a sender whose domain is ********************, or not one of our recruitment partners, please be aware that those communications are not coming from or authorized by Healthfirst. Healthfirst will never ask you for money during the recruitment or onboarding process. Hiring Range*: Greater New York City Area (NY, NJ, CT residents): $47,403 - $64,338 All Other Locations (within approved locations): $41,101 - $60,320 As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision. In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live. *The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.

The RN or SW Clinical Facilitator coordinates with Clinical Teams and other internal stakeholders to advance Healthfirst's clinical practice through technical assistance, education, and innovation solutions by applying adult learning theory. The technical assistance solutions will ensure efficient and effective quality of care in accordance to Healthfirst standards and rules/regulations set forth by state, and federal regulatory and compliance agencies. Within the Clinical Division at Healthfirst, the Clinical Technical Assistance Center (CTAC) will assist clinical employees and other internal stakeholders in tactically obtaining or improving the essential knowledge or skills needed to perform their jobs. The CTAC will also serve as the hub for ongoing adult learning and skills acquisition which supports Healthfirst's commitment to ensuring its teams are capable, engaged, and committed to their work.Leverages adult learning principles and clinical practice standards to move towards a culture of continuous technical assistance improvement and clinical capacity building with innovative learning solutions. Develops technical assistance goals that are congruent with the organization and the Clinical Department's mission, vision, and strategic direction. Provides technical assistance, resources and tools that define performance requirements, identify gaps between existing and required performance, analyze root causes that limit performance and recommend and/or implement learning solutions that focus on and deliver business results. Utilizes current literature, research, and evidence-based findings in the design, implementation and evaluation of technical assistance solutions and education programs for staff learning and development. Conducts onboarding, preceptorship, and ongoing professional training to ensure clinical staff are equipped to perform job responsibilities in accordance to Healthfirst standards and rules/regulations set forth by regulatory and compliance agencies. Facilitates with subject matter experts, instructional designers, training agencies and technical assistance facilitators to design and deliver innovative learning solutions for performance enhancements needed to support the clinical department's business objectives. Facilitates updating departmental training manuals, job aids, quick reference guides and the clinical department's policies/procedures. Develop, implement, and evaluate a preceptorship training program curriculum to standardize the quality of preceptorship practices among the clinical teams. Conducts field assessments as needed to evaluate clinical staff and update the preceptorship training program curriculum. Minimum Qualifications: Licensure: Current Registered Professional Nurse or Registered Social Worker (i.e. LMSW or LCSW) in the State of New York. Education: Bachelor's in nursing or social work preferred with previous work experience in education. Three to five years of clinical experience in a specialty area, or combination of staff nurse/leadership experience in the specialty area, i.e. Care Management, Utilization Management, Clinical Eligibility. Excellent skills in the following areas: verbal and written communication, critical thinking, creativity, interpersonal relationships and team building; change management. Demonstrates knowledge base in professional nursing or social work and evidence based practice; participatory leadership, continuous learning environment, current issues and trends in care management and clinical practice, nursing and social work education and development. Ability to travel about 10% of time around downstate New York including Westchester County and Long Island to conduct clinical observations. Preferred Qualifications: Master's degree in Education and understanding of Adult Learning Theory applications to enhance the technical assistance and education of care management and care coordination activities. Ability to assess educational needs and design and develop responsible curricula. Highly developed verbal and written communication skills and the ability to present effectively to small and large groups. Strong interpersonal skills and ability to work effectively at all levels in a collaborative team environment. Certification in relevant clinical area and Nursing or Social Work Professional Development preferred. Intermediate Microsoft Word, Excel, Outlook and PowerPoint skills WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability 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 *********************** or calling ************ . 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 All hiring and recruitment at Healthfirst is transacted with a valid “@healthfirst.org” email address only or from a recruitment firm representing our Company. Any recruitment firm representing Healthfirst will readily provide you with the name and contact information of the recruiting professional representing the opportunity you are inquiring about. If you receive a communication from a sender whose domain is ********************, or not one of our recruitment partners, please be aware that those communications are not coming from or authorized by Healthfirst. Healthfirst will never ask you for money during the recruitment or onboarding process. Hiring Range*: Greater New York City Area (NY, NJ, CT residents): $81,100 - $117,470 All Other Locations (within approved locations): $71,600 - $106,505 As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision. In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live. *The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.

A vital role of the CMO Administration team, the Medical Peer Reviewer plays a critical role in consulting on medical necessity in the context of utilization management and ensuring adherence to internal Healthfirst and external regulations. Duties/Responsibilities: The Medical Peer Reviewer will assess/review requests for authorization, and claims payment, based on medical records and internal Healthfirst information and make informed clinical judgments and recommendations. The Medical Peer Reviewer will render determinations in the format and within timeframes to follow Regulatory and Operational policies. The Medical Peer Reviewer will: Maintain productivity standards. Collaborate with Utilization Management and Care Management and medical departments as needed, reviews and manages cases/caseload from multiple lines of businesses Demonstrate the ability to be flexible when case load volume fluxes and when Leadership requests changes in case priorities to support our members/internal medical departments as needed Complete mandatory Company compliance training and training in new systems and software. Enter each day's hours worked in Workday, on the same day. Perform other duties as assigned Responsibilities may be adjusted based on changing needs of the organization. Weekday Requirements: The Medical reviewer requires 25 hours a week of coverage/5 days per week. Each Medical Reviewer will cover one legal holiday /year and will be compensated Holiday pay and straight hours worked The Medical Reviewer is eligible for Paid Time Off (PTO) and is required to plan and schedule time off with their direct supervisor following the Company policy. Weekend Requirements: Each Medical Reviewer is required to be primary coverage one weekend a month Each Medical Reviewer is required to be available as back up, if needed, one weekend a month . Minimum Qualifications: Licensed M.D. or D.O. or D.M.D. or D.D.S. Board Certified in a specialty recognized by the American Board of Medical Specialties Preferred Qualifications: New York State Board Certified in Internal Medicine or Family Practice Previous, relevant experience in utilization management and clinical practice Knowledge of Medicare, Medicaid, and MLTC plans Time management, critical thinking, communication, and problem-solving skills Knowledge of UM/QM case philosophies and reporting requirements to state and federal agencies Knowledge of member satisfaction/incident management and regulations Knowledge of quality improvement methodologies Compliance & Regulatory Responsibilities: Ensures compliance to internal Healthfirst and external regulations. Licensed M.D. or D.O. or D.M.D. or D.D.S. Annual Compliance and other training as assigned, may include but not limited to hardware, software, and system training upgrades Annual Inter-Rater Reliability (IRR) Testing Complies with the Healthfirst Conflict of Interest Policy for Professionals WE ARE AN EQUAL OPPORTUNITY EMPLOYER. HF Management Services, LLC complies with all applicable laws and regulations. Applicants and employees are considered for positions and are evaluated without regard to race, color, creed, religion, sex, national origin, sexual orientation, pregnancy, age, disability, genetic information, domestic violence victim status, gender and/or gender identity or expression, military status, veteran status, citizenship or immigration status, height and weight, familial status, marital status, or unemployment status, as well as any other legally protected basis. HF Management Services, LLC shall not discriminate against any disabled employee or applicant in regard to any position for which the employee or applicant is otherwise qualified. If you have a disability under the Americans with Disability Act or a similar law and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to *********************** or calling ************ . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within HF Management Services, LLC will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with HF Management Services, LLC. Know Your Rights All hiring and recruitment at Healthfirst is transacted with a valid “@healthfirst.org” email address only or from a recruitment firm representing our Company. Any recruitment firm representing Healthfirst will readily provide you with the name and contact information of the recruiting professional representing the opportunity you are inquiring about. If you receive a communication from a sender whose domain is ********************, or not one of our recruitment partners, please be aware that those communications are not coming from or authorized by Healthfirst. Healthfirst will never ask you for money during the recruitment or onboarding process. Hiring Range*: Greater New York City Area (NY, NJ, CT residents): $122,907 - $188,020 As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision. In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live. *The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.

**Duties/Responsibilities:** + Provide strategic oversight and operational management for all utilization management functions, including prior authorization, concurrent review, and service requests + Lead, coach, and develop UM managers overseeing interdisciplinary teams of registered nurses, social workers, clinicians, and coordinators + Ensure UM operations meet regulatory requirements set forth by CMS, New York State Department of Health (DOH), and other oversight entities + Establish, monitor, and report on key performance indicators (KPIs), productivity, and quality metrics to ensure compliance and optimal performance + Partner with Clinical Operations, Quality, Compliance, and Provider Relations to ensure alignment and effective communication across departments + Utilize data analytics and reporting tools to identify trends, drive process improvements, and optimize resource allocation + Lead readiness efforts for audits, performance improvement plans, and corrective actions related to utilization management + Foster a culture of accountability, professional development, and continuous improvement across all levels of the team + Serve as a subject matter expert and escalation point for complex or high-impact cases requiring clinical and operational judgment + Support system implementations and technology enhancements to improve automation, reporting, and member/provider experience + Ensure the department maintains timely and accurate completion of service authorizations and reviews in alignment with turnaround time standards + Additional duties as assigned **Minimum Qualifications:** + Bachelors degree in Nursing, Healthcare Administration, or a related field from an accredited institution or equivalent work experience + NYS RN + Demonstrated understanding of UM regulatory requirements, clinical review process, and managed care operations + Leadership experience in managing, coaching and developing multidisciplinary clinical team + Strong analytical, organizational, and problem-solving skills + Work experience demonstrating written and verbal communication skills with the ability to influence and collaborate across functions + Demonstrated success driving high performance and quality outcomes in a fast-paced, regulated environment **Preferred Qualifications:** + Prior experience leading a team of people leaders + Work experience using Milliman Care Guidelines (MCG) criteria and other state-specific authorization requirements. + Ability to interpret and operationalize regulatory updates and guidance from DOH and CMS + Experience working and//or managing in a virtual environment + Understanding of health plans such as Medicare, Medicaid and//or Managed Long-Term Care Plan (MLTCP) + Experience working as a case manager for a long-term care programs such as PACE, MAP or MLTC + Strong understanding of value-based care principles and their application to MLTC populations + Experience accessing and maintaining patient health information (PHI) electronically in a shared network + Strong computer skills, including, but not limited to word processing, spreadsheets, and databases 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, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.

**Duties and Responsibilities:** + Conducts home assessments (and virtual assessments, as needed) for prospective members and re-assessments of current members using the Uniform Assessment System (UAS); make enrollment and continued eligibility determinations by utilizing clinical expertise and critical thinking skills. As needed, conducts assessments in settings other than home as needed, e.g. skilled nursing facilities or virtually + Navigates multiple technology/digital platforms such as UAS software, electronic medical records, TruCare, etc., to conduct and document comprehensive assessments accurately and efficiently + Completes assessment of service needs per CMT and member's family/caregivers request to determine service needs or any necessary adjustments + Reviews previous nursing assessments/medical notes to determine necessary adjustments/updates in Care Plan and//or to assist with nursing home admission + Conducts in-person Care Management visits in support of person-centered service planning + Liaisons between the member and the CMT; assesses home environment and psychosocial status + Provides feedback to home care agencies and CMT regarding home care issues and contract nurses and aides performance + Provides grass roots, community-based training for frail population care including self-care techniques and prevention strategies + Ensures (prospective) members and significant others/responsible parties understand and are in agreement with enrollment in a managed long-term care plan + Additional duties as assigned **Minimum Qualifications:** + New York State RN license + Ability to travel around downstate New York which includes the 5 boroughs, Long Island, Rockland, and Westchester. + Prior work experience requiring technological proficiency including the ability to navigate multiple technology platforms and modalities + Prior work experience requiring intermediate Microsoft Word, Excel, and Outlook skills + Prior work experience requiring time management, critical/creative thinking, communication, and problem-solving skills + For PEDS positions only: 1 year of pediatric clinical field experience and/or experience with families and child serving systems, including child welfare and/or medically fragile/developmentally disabled populations **Preferred Qualifications:** + Work experience using electronic patient health information (PHI) database usage especially UAS + Previous field-based experience assessing, planning, and evaluating member's care by making home or facility visits for intake/reassessments or start of care (SOC) Community Home Health Agency (CHHA) visits + Work experience preferred in one or more of the following areas, geriatrics, home care, discharge planning, case management, and/or medical surgical nursing + Knowledge of health insurance, Medicaid, Medicare and MLTCP + Experience working with a frail adult or elderly population with the ability to determine appropriate care plans and services for frail population as well as negotiate initial service plans so that members and families are in agreement + Language preferences - Spanish, Russian, French, Creole, Mandarin, Cantonese + Demonstrated ability handling heavy caseloads + NY state drivers 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, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.

**Scope of Responsibilities** **:** + Conduct quality audits of A&G items including grievances, pre-service appeals, and post service appeals utilizing appropriate sources of information; including eligibility, claims, authorizations, service forms, faxes, and any additional information required to complete the request. 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 to ensure quality. + 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. + Subsequent auditing and handling of specific appeal and grievance requests including processing where applicable, tracking, documenting, reporting and dispersal of findings and recommendations. + Identify defects and improve departmental performance by supporting quality, operational efficiency and production goals. + Assist in the development of departmental policies and procedures; reviews the efficiency of existing training. + Meet established time frames and rates of performance for the quality and quantity of work for the position. + Participate in regulatory and mock audit activities including universe review, universe scrubbing, risk analysis, timeliness assessment, and case walkthrough activities + Additional duties as assigned **Minimum Qualifications** **:** + Experience with the investigation, resolution, and reporting of appeal and grievance processes. + Experience in Microsoft Office suite of applications including Excel (formatting formulas, managing data, and filtering results), Word (creating and editing documents), PowerPoint (creating and editing presentations). + High School Diploma or GED from an accredited institution. **Preferred Qualifications** **:** + Associate degree from an accredited institution. + ICD10 certification. + Experience in an Auditing capacity conducting root cause analysis. + Knowledge of at least two or more lines of business such as Medicare NY/NJ, Medicaid, Family Health Plus, Child Health Plus, NH Family. + Experience handling confidential information. + Compliance & Regulatory Responsibilities: Knowledge of state and federal appeal and grievance regulatory requirements. 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, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.