Senior Manager, Clinical Eligibility

US-NY-New York
Requisition ID
Department Name


Healthfirst is a provider-sponsored health insurance company that serves more than 1.2 million members in downstate New York. With more than 4,000 employees, a network of nearly 30,000 providers, and revenues in excess of $8.6 billion, Healthfirst is one of the largest health plans in the New York City area.   Our members are our North Star, and our mission is guided by their needs and preferences in ensuring a superior experience and access to the highest quality healthcare when and where they need it. Healthfirst’s commitment to quality and member satisfaction has helped us earn top ratings for HMO health plans in New York City. We know that employees shape our company and connect us to our communities, and we look to recruit and retain intelligent, driven leaders who are passionate about healthcare and embody our five culture drivers: - Dream Big, Plan Wisely - Break Down the Walls - Think Critically, Speak Up, Deliver with Pride - Inspire Through Trust, Lead By Example - Be Unstoppable   Position Summary:   The Senior Mgr of Clinical Eligibility will have knowledge of the current assessment process, for both Medicaid and Medicare programs. This position will support the Assessment Managers in planning, directing, and implementing processes for successful outcomes and achieving goals. The Sr Mgr conducts and contributes to member and family education regarding health management and community resources to enhance population health. This position will be responsible for the overall administration, development, and operation of the Assessment team. Healthfirst is an Equal Opportunity Employer and does not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity or expression, veterans, disability status or any other characteristic protected by law.


 Duties & Responsibilities:  


  • Participates in all aspects of personnel management to ensure appropriate staffing, orientation, support, discipline, and timely performance appraisals.
  • Meets regularly with direct reports to review goals, trends, and performance measures and to facilitate change.
  • Participates in continued staff development to improve the decision-making process. 
  • Provides administrative on-call coverage to troubleshoot and coordinate the delivery of care and services to members.  
  • Manages Assessment Managers to ensure timely assessments and targeted interventions to meet a member’s changing condition(s).
  • Supports the care management teams to ensure effective care management and oversight of home vendor services.
  • Supervises and directs the completion of assessments at established intervals to coincide with care plan development/revision and ensures early identification and action to address emergent issues.
  • Assists members and prospective members with assessment and clinical eligibility questions.
  • Coordinates with contract services to ensure understanding of the MLTC model, FIDA, MAP, and MMCP and cooperation with the assessment process.
  • Ensures coordination with home health, nursing, and social work care as it relates to the care plan.
  • Facilitates problem solving by coordinating case conferences and investigations with the care teams. The Sr Mgr of Clinical Eligibility will function as a facilitator for the team and managers to ensure smooth workflow, efficiency and success within the four programs: PHSP, CC, AE, and SHP.
  • Functions as a liaison to ensure process coordination with different organizational departments such as Intake/Medical Records/CMT/IT/HR/Marketing.
  • Additional duties as assigned.


Minimum Qualifications:   


  • NYS licensed RN

Preferred Qualifications:   

  • Knowledgeable of state and federal regulations including experience interpreting those regulations as it pertains to different programs.
  • Excellent interpersonal skills, especially relating well with a frail adult population, their families and community care providers, along with demonstrated ability to handle rapidly changing crisis situations while still achieving department goals and objectives.
  • Understanding of and sensitivity to cultural differences and needs of the community are essential with a diverse and multi-cultural work environment and community of members such as Spanish, Chinese, Russian, Creole and Korean.
  • Language preferences - Spanish, Russian, French, Creole, Mandarin, Cantonese
  • Bachelor’s degree
  • Intermediate Microsoft Word, Excel, Outlook, Powerpoint, Access, Adobe, Visio, and project skills
  • Proficient navigating internet browsers, computer hardware, and multiple applications simultaneously, using encryption security tools, multiple electronic PHI databases, working in with a VPN and Citrix platform and very accurate typing skills.
  • Demonstrated professionalism and leadership skills along with the ability to develop, direct, and support staff
  • Experience in home care environment, acute, sub-acute or long term care (LTC) setting or managed-long term care (MLTCP). 
  • Experience in one of these areas: managed care organization, PACE, MLTCP, CHHA, licensed agency or a Lombardi program. 
  • Excellent communication, time management, writing, critical thinking, and problem solving skills.
  • Supervisory, training, or management experience.

Regulatory or Compliance activities:

  • Overseeing compliance with SHP standards and time frames for care planning and other recurring activities in accordance with established guidelines and DOH regulations.
  • Collaborating with the Department of Clinical Excellence (DOCE), coordinate orientation and in-service programs to meet regulatory requirements and support performance improvement.


License or Certification: NYS RN license



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