Healthfirst

General

• Process member and non-contracted provider appeals for Healthfirst’s commercial, Medicaid, dual enrollment, Medicare and complete care lines of business
• Develop and resolve non-clinical cases, including certain claim denials, member complaints, and member and provider appeals
• Research issues and reference internal health plan policies and procedures
• Interpret regulations and make critical case-resolution decisions
• Edit and finalize resolution letters
• Manage caseloads and duties within regulatory timeframes
• Communicate with colleagues to hand off or pick up work
• Prepare and submit documented appeals according to payer guidelines and timely filing limits
• Identify denial patterns and trends and provide leadership feedback for process improvement
• Stay current on payer policies, industry regulations and coding updates
• Perform additional duties as assigned

Appeals Specialist

Pharmacist

• 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 medication reviews
• Ensure clinical criteria comply with CMS and NYSDOH requirements
• Research drug information and maintain drug and disease-state knowledge
• Perform and present drug utilization reviews for medical benefit medications
• Complete prior authorization reviews within CMS and/or NYSDOH timeframes
• Work across departments to complete Utilization Management reviews
• Review monthly reports and present trends, efficiency and innovation ideas, and medical spend
• Assist in regulatory and compliance audits for all plans
• Ensure activities comply with applicable regulations
• Perform additional duties as assigned or required

Clinical UM Pharmacist

Infrastructure Engineer

• Establish sustainable design principles across infrastructure systems, cloud platforms, enterprise integration patterns, and emerging AI platform capabilities
• Work across Infrastructure & Operations, Enterprise Delivery Program teams, application teams, data teams, security, and other IT partners
• Provide strategic oversight and planning for enterprise infrastructure and AI platform initiatives
• Design and build Platform Engineering constructs enabling CI/CD and governance for AI Platform consumers
• Define target-state architecture, reference architectures, reusable platform patterns, frameworks, and solution blueprints
• Provide architecture guidance for AWS-first AI platform capabilities and evaluate other cloud, SaaS, and third-party technologies
• Evaluate emerging technologies including AWS AgentCore, Workato, TrueFoundry, AI gateways, LLM platforms, agentic frameworks, RAG, embeddings, policy enforcement, observability, and workflow orchestration tools
• Ensure infrastructure systems, AI platform capabilities, and processes align with IT strategy, security, compliance, and operational standards
• Define platform design, support requirements, operational guardrails, implementation patterns, and handoff expectations with I&O engineering teams
• Design infrastructure patterns integrating AI platforms with systems of record, APIs, event-driven architectures, data platforms, identity systems, secrets management, observability, and IT service management
• Account for regulated-environment requirements including data protection, access control, auditability, PHI/PII handling, resiliency, vendor risk, and compliance-by-design
• Identify architectural risks, technical debt, scalability concerns, compliance gaps, vendor lock-in, cost-management issues, and operational support limitations
• Lead or participate in proofs of concept, sandbox validation, and early development-environment architecture validation
• Produce component specifications, candidate architectures, roadmaps, policies, standards, and practices
• Define observability, capacity, performance, and cost-management patterns
• Present architecture recommendations to senior IT leaders and influence technology decisions without direct management authority

AI Infrastructure Architect

Learning and Development

• Design and develop holistic, multimodal learning programs aligned with Healthfirst culture and digital transformation
• Partner with stakeholders and subject matter experts to identify objectives, requirements, outcomes, evaluation measures and success metrics
• Develop asynchronous and synchronous learning materials, course outlines, storyboards, facilitator guides, participant guides and exercise guides
• Create engaging, creative and instructionally valid learning solutions and experiential courseware
• Develop multimedia assets using Adobe Creative Suite or comparable tools
• Collaborate with stakeholders to iteratively improve learning and business outcomes
• Maintain current learning materials, digital pre-work, post-work, presentations, handouts, communications, guides and job aids
• Review peer-developed content and provide feedback
• Create training communications and sustainability plans
• Monitor feedback and enhance programs for accuracy, relevance, effectiveness and adoption
• Coordinate with business leaders and project managers on training schedules and resourcing
• Research learning trends, technologies and innovations and recommend their use at Healthfirst
• Establish learning-design methodologies, standards, processes, approaches and timelines
• Customize learning interventions with business leaders and HR Business Partners
• Support capability building for Business Transformation efforts
• Plan environments, users and data staging for development projects
• Develop measures, benchmarks and scorecards to monitor effectiveness
• Mentor and provide technical guidance to pedagogy specialists
• Lead cross-functional learning projects and manage third-party contributors and vendors
• Conduct external research and benchmarking
• Perform additional responsibilities as assigned

Senior Instructional Designer

Manager

• Manage and monitor appeal inventory for a team of Appeals & Grievances Clinical Specialists
• Prepare and plan weekend staff assignments and volume to ensure compliance
• Triage and assign expedited appeals and optimize appeals and grievances routing
• Manage weekend inventory to ensure regulatory compliance
• Communicate and escalate cases to Medical Peer reviewers
• Maintain delegated vendor relationships and monitor vendor performance and compliance
• Coordinate with outside departments for case escalation, clarifications and appeal resolution
• Manage letter review and printing and coordinate expedited printing with the mailroom
• Review case change requests and cancellations and route follow-up appropriately
• Review and submit Level 2 appeals packets
• Maintain knowledge of industry trends, best practices and protocols and share enhancements across enterprise units
• Identify trends and recommend improvement solutions
• Deploy approaches to meet production, compliance and quality targets
• Build partnerships across and outside operations to improve communication and responsiveness
• Provide feedback and recommendations to leadership concerning staff performance
• Comply with HIPAA and maintain confidentiality
• Adhere to state and federal compliance and regulatory guidelines
• Perform additional duties as assigned

Manager, Clinical Appeals – Grievances

Operations

• Provide strategic and operational leadership for clinical utilization management activities, focusing on UM modernization and transformation
• Partner with the Vice President, UM leadership, external consultants, and project management resources to shape future-state workflows and support technology-enabled transformation
• Oversee people leaders responsible for medical necessity review, service authorization, care coordination, and related UM functions
• Design and implement future-state UM workflows, processes, and operating practices
• Collaborate with leadership, consultants, project management, technology, and vendor teams on UM transformation priorities
• Identify clinical and operational requirements, risks, dependencies, and impacts to frontline teams
• Support stakeholder engagement, training, implementation, operational readiness, adoption, and stabilization of new technologies and workflows
• Identify and advance AI, automation, and emerging technology opportunities aligned with clinical workflows, compliance, audit requirements, and user needs
• Provide oversight for prior authorization, concurrent review, and service requests
• Lead, coach, and develop UM managers overseeing interdisciplinary clinical teams
• Ensure compliance with CMS, New York State DOH, and other regulatory requirements
• Establish, monitor, and report KPIs, productivity, and quality metrics
• Partner with Clinical Operations, Quality, Compliance, and Provider Relations
• Use data analytics and reporting tools to identify trends, improve processes, and optimize resource allocation
• Lead audit readiness, performance improvement plans, and corrective actions
• Serve as a subject matter expert and escalation point for complex cases
• Support system implementations and technology enhancements
• Ensure timely and accurate completion of authorizations and reviews

Senior Manager, Clinical UM Operations – Automation

• Provide daily oversight for Case Management teams, including RNs, Social Workers, and Coordinators
• Ensure high-quality, cost-effective, and appropriate allocation of member services, treatments, and resources
• Serve as a resource to Healthfirst’s care management team, members, and outside medical providers
• Oversee utilization management functions, including timely authorizations for pre-certification, concurrent review, referrals, and other plan services
• Develop and monitor staff goals; provide feedback and coaching; conduct annual performance reviews
• Lead by example and foster open communication, teamwork, ownership, and empowered decision-making
• Collaborate with medical staff and review medical charts to obtain information for utilization management and resolve complex clinical problems
• Develop and analyze operational and analytical reports to monitor operational efficiency
• Document utilization management activities and decision rationales in electronic medical records systems
• Function as a clinical resource for the multidisciplinary care team to maximize patient-care quality and manage medical costs
• Perform additional duties as assigned

Clinical Utilization Review Manager

• Coordinate care plans for assigned members
• Conduct pre-certification, concurrent review, discharge planning, and case management
• Perform risk identification, preadmission, concurrent, and retrospective reviews for treatment appropriateness and medical necessity using clinical documentation, regulatory, and InterQual/MCG criteria
• Identify medical, psychological, and social issues requiring intervention
• Partner with PCPs and other medical providers to coordinate treatments, collateral services, and service authorizations
• Negotiate rates with non-partner providers where applicable
• Ensure access to and utilization of network and community resources
• Document determinations, notifications, interventions, and telephone encounters according to standards and regulations
• Advocate, inform, and educate beneficiaries on services, self-management techniques, and health benefits
• Develop and execute care plans aligned with physician treatment plans
• Report and escalate questionable healthcare services
• Monitor caseloads and meet performance metrics
• Serve as a clinical resource for the multidisciplinary care team to maximize member care quality and manage medical costs
• Identify and facilitate alternative care options
• Work occasional overtime as necessary
• Perform additional assigned duties

Case Manager – Utilization Management II

• Prepare and plan weekend staff assignments and volume to ensure compliance
• Triage and assign expedited appeals
• Standardize and optimize Appeals and Grievances routing
• Manage weekend appeal inventory to ensure regulatory compliance
• Communicate and escalate cases to Medical Peer reviewers
• Maintain delegated vendor relationships and monitor vendor performance and compliance
• Coordinate with outside departments on escalations, clarifications and appeal resolution
• Manage letter review and printing and coordinate expedited printing with the mailroom
• Review case change requests and cancellations and route follow-up appropriately
• Review and submit Level 2 appeals packets to the appropriate entity
• Maintain knowledge of industry trends, best practices and protocols
• Identify trends and recommend improvement solutions
• Deploy approaches to meet production, compliance and quality targets
• Build partnerships across and outside operations
• Provide feedback and recommendations to leadership on staff performance
• Maintain confidentiality of member, provider, medical and departmental information
• Perform additional duties as assigned

Manager, Clinical Appeals & Grievances

Auditor

• Audit data, claim submissions, and member medical records for completeness, accuracy, and compliance with Healthfirst policy
• Document audit findings according to departmental procedure
• Identify patterns of under-performance, noncompliance, and inconsistencies and recommend resolutions
• Evaluate medical coding quality and notify management of discrepancies
• Conduct internal audits of medical record reviews performed by colleagues
• Collaborate with departments to improve compliance with coding conventions and clinical practice guidelines
• Support continuous improvement and quality initiatives across departments
• Perform additional duties as assigned

Coding Auditor

• Assist care/case managers with non-clinical activities such as creating cases and events
• Provide telephonic outreach to members, providers and community-based organizations
• Handle member mailings
• Fax clinical requests and Individual Health Care Plans on behalf of care/case managers
• Conduct outreaches for newly enrolled members to review current and approved services, DME and additional requests
• Review intake documents for pre-approved services and escalate discrepancies as needed
• Complete Welcome Onboarding and Consumer Directed Personal Assistant Assessments and identify issues or risk factors requiring clinical escalations
• Initiate and finalize authorization in Trucare for preapproved services and DMEs; update and discontinue authorizations when applicable
• Handle and accurately document calls from and to members regarding benefit questions/issues, appointments, assessments, service issues and grievances
• Handle and accurately document calls from and to providers regarding authorizations, referrals, visits, tests and faxed care plans
• Educate members and providers regarding requirements for approval of service requests
• Manage a large caseload while communicating member issues or needs and monitoring screening of members to improve quality and cost outcomes
• Communicate with Inter/Intra-departments regarding reconciling onboarding issues
• Perform additional duties as assigned

Support Coordinator

• Assist care/case managers with non-clinical activities such as creating cases and events
• Provide telephonic outreach to members, providers and community-based organizations
• Handle member mailings
• Fax clinical requests and Individual Health Care Plans on behalf of care/case managers
• Conduct outreach for newly enrolled members to review current and approved services, durable medical equipment (DME) and additional requests
• Review intake documents for pre-approved services and escalate discrepancies as needed
• Complete Welcome Onboarding and Consumer Directed Personal Assistant Assessments and identify issues or risk factors requiring clinical escalations
• Initiate, finalize, update and discontinue authorizations in Trucare for preapproved services and DMEs
• Document calls involving benefit questions, appointments, assessments, service issues and grievances
• Document provider calls regarding authorizations, referrals, visits, tests and faxed care plans
• Educate members and providers regarding requirements for approval of service requests
• Manage a large caseload and monitor member screening to improve quality and cost outcomes
• Communicate with inter/intra-departments to reconcile onboarding issues
• Perform additional duties as assigned

Analyst

• Serve as a triage coordinator for provider disputes and determine appropriate resolution pathways
• Analyze dispute populations to identify trends, root causes, and lower-cost resolution opportunities
• Perform independent coding analysis and disposition complex claims, disputes, and appeals
• Identify high-volume and high-cost dispute scenarios and develop population-level solutions
• Recommend and support changes to claims edits, configuration, payment policies, workflows, automation, and provider education
• Partner with Claims, Provider Operations, Configuration, Technology, Payment Integrity, and other stakeholders
• Monitor dispute volume, overturn and repeat rates, turnaround time, administrative cost, and resolution outcomes
• Serve as a coding and payment policy subject matter expert
• Review medical records as needed to determine appropriate coding and claim disposition
• Communicate coding and payment decisions to providers and internal stakeholders
• Lead continuous improvement efforts to reduce avoidable disputes and administrative expense
• Provide day-to-day guidance and mentorship to Claims Coding Analysts
• Perform additional duties and special projects as assigned

Appeals Specialist

Clinical UM Pharmacist

AI Infrastructure Architect

Senior Instructional Designer

Manager, Clinical Appeals – Grievances

Senior Manager, Clinical UM Operations – Automation

Clinical Utilization Review Manager

Case Manager – Utilization Management II

Manager, Clinical Appeals & Grievances

Coding Auditor

Support Coordinator

Support Coordinator

Senior Claims Coding Analyst