Teams at Healthfirst, Inc

Coordinates clinical documentation and coding projects supporting CMS RADV audits and health plan quality objectives. Responsibilities include improving medical record acquisition, auditing documentation, educating stakeholders on coding practices, analyzing clinical and invoice data, identifying process improvement opportunities, preparing reports and presentations, supporting CMS audit initiatives, and ensuring medical record accuracy, completeness, HIPAA compliance, and regulatory adherence.

Conducts audits of medical records, claims, and diagnostic coding for accuracy, completeness, and compliance with CMS, NYSDOH, and organizational policies. Identifies coding discrepancies, noncompliance, and performance trends; documents findings and recommends resolutions. Reviews colleagues’ medical record audits, collaborates across departments to improve coding practices and clinical guideline compliance, and supports continuous quality improvement initiatives.

Supports care and case managers with non-clinical coordination, authorization management, member and provider outreach, case documentation, mailings, faxing, scheduling, and issue escalation. Handles high-volume queues while maintaining quality, productivity, HIPAA compliance, and confidentiality. Provides customer service, updates member information, communicates care needs, and coordinates with internal teams, providers, and community organizations. Spanish fluency is preferred, along with healthcare, managed care, medical terminology, and CRM experience.