Hedis Auditor And Data Analyst resume example

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)