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Click here or scroll down to respond to this candidateCandidate's Name , CPCStreet Address PHONE NUMBER AVAILABLE(cell)EMAIL AVAILABLEExperienced investigational auditor with knowledge of health insurance business, industry terminology, and regulatory guidelines. Including government and state agency auditing and fraud waste and abuse payment integrity. HCC, HEDIS Certified Medical Coder with history of remote and on-site abstraction of information from EMR and paper medical records. Investigational auditing experience, including government and state agency auditing. Working knowledge of manuals and guidelines for ICD-10-CM, CPT, HCPCS, HEDIS Measures, NCQA requirements, HCC, CCC, TAMPER and MEAT. Proficient in medical terminology, anatomy/physiology, electronic health records, and electronic medical records including Next Gen., Epic, and Meditech. My education includes an ASN(Associates of Science in Nursing). Currently enrolled in the Bachelors of Science in Health Informatics program at Western Governors University, anticipating receiving my RHIA. WORK EXPERIENCEUnited Health Group, October 2018-PresentQuality Assurance Claims Auditor Consultant, May 2022-Present Responsible for Quality Assurance conducting audits and providing feedback to reduce errors and improve processes and performance. Ensure accurate reviews and determinations are being completed from investigator to investigator. Including Professional and Facility cases for WLCR, MLNA and ACFC. Recovery Resolution Analyst Sr, October 2018-May 2022 Remotely investigate, review and provide clinical and/or coding expertise in a review of post-service, pre-payment or post-payment claims, including Facility and Professional for Wellcare. Ive also assisted MLNA as needed with facility cases.Interpretation of state and federal mandates, billing practices/patterns, applicable benefit language, medical and reimbursement policies, coding requirements and consideration of relevant clinical information on claims with overt billing patterns and make recommendation decisions based on findings.Provide coaching and education to reduce errors and improve client survey scores. Identifies overt billing trends, waste and error identification, and recommends providers to be flagged or filtered for review.Identifies updated clinical analytics opportunities and participates in projects necessary by client/other departments.Ability to navigate through multiple claims applications (COSMOS, UNET, Facets, Pulse, etc.), to aid in research and work independently on making decisions on complex cases. Maintains and manages daily case review assignments, with a high emphasis on quality, with at least 98% accuracy while following client/CMS guidelines. Provides clinical explanation both to the provider and client in case management systems. Participates in client/network meetings, which may include process changes and participates in additional projects as needed.Assume additional responsibilities as assigned.Analyze/research/understand how a claim was identified by Payment Integrity and determine appropriate resolution pathWork with applicable business partners to obtain additional information relevant to the Payment Integrity case to drive resolution (e.g., Network Management, Claim Operations, OGS, UCHPI) Comprehend and adhere to applicable federal/state laws and regulations (e.g., DOI, ERISA, HIPAA, CMS) Aerotek (Cleveland Clinic)/Remote HCC Auditor, October 2017-December 2017 Remotely review HER/EMR to assign appropriate ICD-10-CM codes, creating HCC and/or RxHCC group assignments as applicable. Participate in meetings as required. Query charts as necessary. Maintained above a 95% accuracy rate and met daily quotas.Altegra Health/Remote HCC inpatient and Outpatient Coder, September 2015-January 2015 Remote HEDIS (Diabetes) January 2015-May 2016Remotely abstract information from patient medical records. Assign ICD-9 and/or ICD-10-CM codes, creating HCC and/or RxHCC group assignments. Assign Altegra Health Flagged Event codes when documentation in the record is inadequate, ambiguous, or otherwise unclear. Remain current on medical coding guidelines and reimbursement reporting requirements. Check chart assignments every day and report accurately all hours worked on a weekly basis. Report work-related concerns to assigned Coder Advocate.Comply with the Standards of Ethical Coding as set forth by the American Health Information Management Association and adhere to official coding guidelines. Comply with HIPPA laws and regulations. Participate in testing and training as required by the Company. Inovalon/HEDIS and HCC Chart Abstraction January 2011-May 2011; January 2013-May2013 Travel to various physician offices auditing patient charts for various health insurance purposes. Review medical records to verify or gather information. HEDIS audit/abstraction looking at different types of care and the kind of care given as a means of grading the health insurance plan. Risk Adjustment/Claims integrity to verify diagnosis and procedure codes match the medical codes listed in the billing to avoid overpayment and underpayment.Premier Visiting Nurse/Clinical Nurse Supervisor, April 2013-September 2013 Supervision and coordination of clinical team including RNs, LPNs, HHAs and office staff to ensure safe, cost effective care to home bound patients. Physician orders received via fax are reviewed for information related to case such as patient demographics, clinical diagnosis, medications, and disciplines. Code and process applications (OASIS) into required electronic format. Assign correct ICD-9 codes related to diagnosis, correct CPT, and E/M codes following proper guidelines. Instruct and guide clinicians to promote effective performance and delivery of quality home care services according to NCQA requirements and CMS guidelines to ensure proper payment, and compliance initiated by CMS, government organizations or commercial payers.Michigan Dept of Community Health/Case Manager, December 2008-June 2010 Medication administration, assessment, planning, implementing and evaluating patients. Perform interviews to identify specific patient needs and prioritizing action based upon patient care requirements including assessing admission and discharge criteria. Triaging patients for medical care and extensive communication with the various members of the treatment team. Conducted groups such as medication education, anger management, and the effects of blood sugar on behavioral health symptoms, Evaluate and assign Axis codes.Liken Health Care/HCC and HEDIS Medical Chart Abstraction, January 2008-May 2008 Travel to various physician offices auditing patient charts for various health insurance purposes. Review medical records to verify or gather information. HEDIS audit/abstraction looking at different types of care and the kind of care given as a means of grading the health insurance plan. Risk Adjustment/Claims integrity to verify diagnosis and procedure codes match the medical codes listed in the billing to avoid overpayment and underpayment.Mt St. Marys Hospital/RN Ambulatory Surgery Unit, December 2002-September 2008 Direct patient care in an ambulatory hospital setting medically preparing patients for surgery, post-op care and instructions for discharge home. Outpatient chemotherapy, blood transfusions, natrecor and blood draws via mediportEDUCATION/PROFESSIONAL LICENSE/CERTIFICATIONWestern Governors University/BS in Health Informatics, 1/2022-Present Wayne.County Community College/ASN 2002CPC/AAPC Membership #01440770RN NY State #536909 active 2002-2011 |
