Healthfirst Documentation & Coding Audit, Team Lead in New York, New York


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

Healthfirst is an Equal Opportunity Employer and does not discriminated 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.

Position Summary:

The Documentation & Coding Audit Team Lead supervises staff and processes associated with auditing clinical documentation that supports Healthfirst diagnoses submitted to CMS (Centers for Medicare and Medicaid Services), New York State, and other entities in support of appropriate risk scores of Healthfirst members. This position will oversee direct review of provider documentation and also completion of audits of vendors that Healthfirst contracts to do clinical review of documentation. This position reports to the Director, Documentation and Coding.


Duties & Responsibilities

  • Oversee the day-to-day operations of all documentation and coding audit processes as well as the coding analysts and coordinators' activities. Included functions include working distribution to all direct reports, evaluating daily productivity, tracking and monitoring retrievals and audits outcomes, ensuring medical record retrievals are done in accordance with internal and external regulatory requirements.

  • Manage all vendors' activities related to risk adjustment audits, which include providing audit samples, the management of vendors' medical record retrievals and chart review workloads inside and out of the organization.

  • Tracking and monitoring each vendor's progress in meeting deadlines; ensure data is reported accurately and completely; evaluate performance improvements in relation to corrective action plans; analyze data collection for patterns and trends to identify opportunities to improve documentation and coding as well as report outcomes & assessments to various internal and external stakeholders as applicable.

  • Perform quality assurance reviews of coding analysts' audit findings, which may include pulling samples of unsubstantiated diagnoses in order to validate the accuracy of the reviews. Frequently communicate effective feedback and provide decision support to reviewers on coding issues, as needed engage the vendor.

  • Conduct periodic (i.e. monthly) risk adjustment workgroups that include case studies and Q&A sessions. Inform the team of all changes/updates made to the risk adjustment model(s), CMS (Centers for Medicare and Medicaid Services) and other regulatory guidance & coding guidelines, and provide clarification as needed.

  • Develop and implement processes and workflows around the execution of audits; maintain documentation and chart review audit results consistent with internal standard operational procedures as well as CMS and other governmental regulations and our company's goals and policies.

  • Ensure all stored medical records have gone through the internal quality assurance process.

  • Additional duties as assigned


Minimum Qualifications:

  • One of the following educational requirements:

  • Bachelor's Degree with acoding certification from American Academy of Professional Coders or American Health Information Management Association

  • OR

  • Diploma or Associate's or Bachelor's or higher degree in Nursing with RN License

  • Coding experience

  • Supervisory experience

Preferred Qualifications:

  • ICD-10 recognized.

  • Experience creating and editing presentations using Microsoft PowerPoint.

  • Work experience within a medical record and coding auditing setting.

  • Understanding of Medicare and Medicaid risk adjustment regulations and guidelines.

  • Experience creating and editing documents in Microsoft Word.

  • Experience using Microsoft Excel to create, edit and manipulate data.

  • Work experience in a supervisory role for medical records or in a coding setting.

  • Experience communicating and presenting to cross functional groups within an organization.

License/Certification: Certification in American Academy of Professional Coders, or American Health Information Management Association, or Clinician.

Requisition ID 2017-15084

Job Locations US-NY-New York

Department Name Documentation and Coding

Equal Opp Statement -

Healthfirst is an Equal Opportunity Employer and does not discriminated 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.

Reasonable accommodation statement -

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 1-800-401-6000. 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.