ACA, Healthcare ReformPopulation Health
Perform Medical Record Review to retrieve documentation for specific information related to HEDIS clinical measures
Met interrater reliability thresholds for performance prior to and throughout abstraction timeframe
Develop and maintain ACA preventive services database with appropriate codes and services covered by CMS, USPSTF, Bright Futures
Utilize GEMS and Reimbursement mapping of ICD9 and ICD10 for historical clinical data analysis
Experience navigating different EHR systems (Cerner, Allscripts, NexGen) for data collection and auditing of Population Health providers
Analysis and data mining of external Fraud Waste and Abuse database using historical medical and pharmacy claims data.
Identify, educate and prevent FWA by ascertaining appropriate coding rules, guidelines and claim editing.
Advise PCMH offices on required documentation and data reporting of electronic health records (EHR) for NCQA recognition
Provide education to providers, office managers and staff regarding Medicare risk adjustment and the importance of documentation and accurate coding of on-going chronic conditions for PTHP enrollees
Optimized monthly capitation payments to Primetime based on targeted audits which resulted in additional payer revenue to provide coordinate care for enrollees with high level chronic conditions
Project lead for member problem list development through data mining of claims to report confirmed chronic and suspected conditions based on clinical data reported on valid claims
Conduct revenue recovery and data validation audits of medical record documentation with claims data to determine if charges, units and CPT codes correlate with services documented.
Identified physician point of care services and procedures performed at patient bedside that were not captured through the chargemaster
Design and utilize audit tools to capture and monitor the accuracy of clinical coding
Presented a certified independent MS-DRG validation audit for Aultman LTAC required by external financial auditors for dates of services 2006-2010
Perform Encounter Data Omission Studies for Health Services Advisory Group, Medicaid QIOContract trainer for MedAssets (2005-2006)Contract trainer for MedAssets (2005-2007) on Chargemaster (CDM) management software
RHIA American Health Information Management Association
CCS-P American Health Information Management Association
CCS American Health Information Management Association
NAHQ Plan on taking Professional in Healthcare Quality (CPHQ) certification
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