Job Description

Duties & Responsibilities Assess and review requests for authorization and claims payment based on medical records and internal Healthfirst information; make informed clinical judgments and recommendations. Render determinations in the required format and within timeframes to follow regulatory and operational policies. Maintain productivity standards. Collaborate with Utilization Management, Care Management, and medical departments as needed, reviewing and managing cases/caseload from multiple lines of businesses. Demonstrate flexibility when case load volume fluctuates or when leadership requests changes in case priorities to support members and internal medical departments. 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 25 hours a week of coverage, 5 days per week. Cover one legal holiday per year and receive holiday pay and straight hours worked. Eligible for paid time off (PTO) and required to plan and schedule time off with direct supervisor following company policy. Each Medical Reviewer is required to be primary coverage one weekend a month. Each Medical Reviewer is required to be available as backup, if needed, one weekend a month. Minimum Qualifications Licensed M.D., D.O., D.M.D., or D.D.S. Board Certified in a specialty recognized by the American Board of Medical Specialties. Preferred Qualifications 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 Ensure compliance to internal Healthfirst and external regulations. Annual compliance and other training as assigned, including but not limited to hardware, software, and system training upgrades. Annual Inter‑Rater Reliability (IRR) testing. Comply with the Healthfirst Conflict of Interest Policy for Professionals. Hiring Range* Greater New York City Area (NY, NJ, CT residents): $119,891 - $183,430. 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 careers@Healthfirst.org or calling 212‑519‑1798. In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within 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. #J-18808-Ljbffr Healthfirst, Inc.

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