Process-driven Compliance Analyst practiced in assessing, tracking and documenting information. Adept at reviewing medical records, employee work, company standards and supporting materials in order to make a clear assessment and offer effective solutions. Strong background in Revenue Cycle Management, professional coding, process improvement, professional claims audit, special investigations and data analysis. Prepared to offer 15 years of clinical and administrative healthcare experience to growth-oriented company.
- Manages the onboarding process, including risk assessment of newly acquired First Tier, Downstream, and Related Entities including contract maintenance.
- Assists leaders with the development, update, revision, and/or implementation of contracts, policies, procedures and practices for the general compliance and operations.
- Coordinates with other departments to gather information needed for regulatory reviews, validations, and audits.
- Assists with the compliance oversight of First Tier, Downstream, and Related Entity requirements including exclusion screening, distribution of Code and Standards of Conduct, compliance with all applicable training requirements, monitoring and auditing of downstream entities, appropriate reporting mechanisms for fraud, waste and abuse compliance issues, and HIPAA Privacy controls.
- Create and monitor Key Performance Indicators for multiple business areas.
- Assists with the investigation, auditing, review and analysis of general compliance, FWA, and other matters to ensure compliance with governmental regulations and internal policies.
- Assist with coordinating the implementation and completion of corrective action plans by various business area.
- Drafts and submits responses to external inquiries and requests.
- Data analysis/report creation
- Helping identify areas for audit opportunities based on industry performance, regulatory focus areas and risk areas within the organization.
- Manage multiple tasks simultaneously ensuring timely execution in a fast-paced
- Facilitated the successful procuring of insurance authorizations for ordered procedures and post-operative care.
- Quality validations of obtained authorizations as well as continuous education with the underlying objective of managing the cost of care and providing timely and accurate information to payers.
- Helped drive change by identifying areas where performance improvement is needed in areas of day to day workflow, education, process improvements, patient satisfaction.
- Maintained designated case load and plan effectively in order to meet demands and support resources procuring authorizations.
- Ensured feedback relevant to successful authorization procurement is obtained from back end coding, billing and denial management resources and distributed to ordering physicians and authorization procurement staff to promote continuous improvement.
- Responsibilities included acting as a centralized resource for assigned specialty across all sites of practice to ensure standardized and consistent procurement of authorizations.
- Software: EPIC software, Protocol, Microsoft Office Suite 2010
- Providing investigative staff support by analyzing,identifying and investigating data obtained from SAS Predictive Data Analytics (member,provider,pharmacy utilization), SIRIS/LEXUS,NHCAA, Anti Fraud Hotline reports, potential healthcare fraud, waste and abuse schemes/data provided from multiple internal/external sources including internet researching and proactive data mining.
- Research, analyze and collect necessary data to prepare cases for manager,clinical,legal review and audit.
- Request and review chart pulls for billing/coding compliance, medical necessity and plan guidelines.
- Compile reports and documentation into understandable spreadsheets for investigators, law enforcement, analysts and other support personnel.
- Determine recovery opportunities identified from fraudulent, abusive or erroneous claim activities.
- Financial analysis compiling corporate loss and financial exposure.
- Interact with Fraud Investigators, HHS-OIG, law enforcement on the analysis and interpretation of claims,utilization, transaction/field data,policies and procedures.
- Diligently focusing on medical necessity, compliance, fraud, waste, abuse schemes/trends and cost containment within the healthcare industry.
- Systems: SAS, SIRIS, Metric Stream, Team Connect, NASCO, NCSW, IKA, Portico.
- Examined patients' insurance coverage, precisely evaluated and verified benefits and eligibility, deductibles, possible insurance carrier payments and remaining balances not covered under their policies when applicable.
- Pre-certified medical and radiology procedures as needed.
- Reviewed, analyzed and managed coding of professional and diagnostic treatment procedures contained in outpatient medical records.
- Interacted with providers and other medical professionals regarding billing and documentation policies, procedures and regulations.
- Researched questions and concerns from providers and provided detailed responses.
- Correctly coded and billed medical claims for various professional services researching newly identified diagnoses and/or medical procedures to expand skills and knowledge compliant with ICD10, CPT and HCPCS and CMS guidelines.
- Conscientiously reviewed medical record information to identify appropriate coding based on CMS HCC categories Reviewed and resolved claim issues captured in TES/CLAIMS edits and the clearing house.
- Meticulously identified and rectified inconsistencies, deficiencies and discrepancies in medical documentation.
- Supported timely, accurate charge capture, coding assignments, billing functions and revenue cycle process through record audit and education.
- Posted and adjusted payments from insurance companies ensuring correct reimbursement according to contracts and guidelines.
- Confidently and adeptly handled claim denials and/or appeals.
Specialties: Family Practice, Addiction Medicine, Weight Control, Laboratory, Diagnostic Radiology
Dean's List Honoree
Senior Status- 130 credit hrs complete
- Certified Processional Coder CPC
- Certified Professional Compliance Officer CPCO
- Certified Professional Biller CPB
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