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Regulatory Healthcare Compliance Audit Manager resume example with 13+ years of experience

Jessica
Claire
resumesample@example.com
(555) 432-1000,
, , 100 Montgomery St. 10th Floor
:
Professional Summary

A proven and effective Medical Records Director with over 10 years experience in. An expert at establishing compliant audit objectives and overall scope. A proven track record of improving the effectiveness of existing risk management, controls, and governance processes. A true leader who is able to bring my skills, technical knowledge, energy, and motivation to steer and influence a business at a critical time. Skilled verbal and written communicator with a proven record of consistently improving the effectiveness of existing foundational and strategic risk management controls and governance processes with win-win scenarios. Self-directed with intense personal motivation and a commitment to exceeding the expectations of business compliance objectives and foundational goals. Expert skill level and tasks with most advanced complexity and broad enterprise scale in the ability to direct and manage projects, initiatives, lead compliance monitoring to identify process gaps, lead complex investigations, develop, lead and execute complex plans, and develop strong relationships with key stakeholders to mitigate compliance risk. Known for supervising simultaneous projects in high-pressure environments with professionalism and poise. Collaborative and team-oriented with excellent communication and interpersonal skills to foster strategic partnerships and promote company reputation.

Skills
  • Process Management
  • Conducting investigations
  • Quality controls
  • Internal Audits
  • Document reviews
  • Risk analysis
  • Compliance documentation
  • Information gathering
  • Investigations skills
  • Policy analysis
Education
Phoenix University Chicago, IL Expected in PHD of Science : Healthcare Management - GPA :
Phoenix University and Corllins University Chicago, IL Expected in Master of Science : Healthcare Management - GPA :
Certifications
  • Certified Professional Coder (CPC), American Academy of Professional Coders (AAPC),1999
  • Certified Healthcare Compliance (CHC), Healthcare Compliance Association (HCA), 2009
  • Professional Medical Coding Curriculum (PMCC) Instructor, American Academy of Professional Coders (AAPC), 2008
  • Certified Risk Coder (CRC), American Academy of Professional Coders (AAPC), 2018
  • Expert Technical Proficiencies: Microsoft Office (Word, Excel, PowerPoint, Outlook, Access, One Note, Share point, Publisher Skype, Zoom & AS400
  • EMR Proficiencies: EPIC, CERNER, Athenahealth, NEXTGEN, eClinicalWorks, Allscripts, & McKesson
Work History
Crowe Healthcare - REGULATORY HEALTHCARE COMPLIANCE AUDIT MANAGER
City, STATE, 07/2015 - 04/2020
  • Performed risk assessment for a hospital system and identified process breakdowns in the hospital billing, collections, and cash posting processes, and implement innovative solutions to address new issues that arise.
  • Discovered population of aged accounts that needed resolution which helped relieve A/R by $4M.
  • Implemented payer escalation process with top insurers resulting in payments of $2M.
  • Managed project timelines and ensuring that clients generated significant value from partnership with the Advisory Board Educated executives and staff on ICD-10, clinical documentation, Risk Adjustment Coding, RAC programs, and revenue impact and enhancement topics; identified areas of opportunity and risk to prioritize strategies within long-term plan.
  • Performed detailed ICD-10 and CPT coding and reimbursement audits with deliverables and remediation to client coding staff from both professional/physician and an outpatient hospital perspective.
  • Evaluated clinical and coding practice operations of a medical practice.
  • Developed and implemented action initiatives and streamlined processes and provided remediation services that significant decreased compliance risk and improved revenue enhancement.
  • Audit Manager at Crowe Healthcare formerly CHAN Healthcare the first and remains the only company in the nation focused exclusively on providing internal audit services to the healthcare industry.
  • Lead audit professional for both the client and engagement base team with responsibility of providing hospital health systems internal audit services, client risk assessments, audit findings recommendations, creating policies and procedures, corporate compliance plans, and remediation to mitigate identified risk areas.
  • In addition, provide engagement base audit services for physician base professional practices and major payers with deep specialization through an understanding of the market and business challenges clients face and a expertise in regulatory guidelines, HIPAA compliance, Stark and Anti-Kickback laws, audit quality, and risk assessments.
  • Handled over $150 million in multiple client’s engagement contracts from Tier-1 clients (major hospital systems) – identifying and resolving gaps in controls and mitigating critical compliance risk areas.
  • Provided hands-on leadership and technical direction to Quality staff in achieving department strategic, tactical, and quality goals.
  • Established, improved, and executed Quality strategy and goals aligned with the company’s overall plan.
  • Successfully ensured that the organization was trained to the highest standards of Quality excellence and technical competency utilizing best in class processes and practices.
  • Developed and implemented quality systems designed to reduce and/or eliminate non-conformances, increased efficiencies, strengthen quality and compliance departments infra-structure through education, training, performance-based risk assessments.
  • Established and monitored specific client individual goals and objectives.
  • Sets goals and expectations for the client, aligned performance and rewards, appropriately address performance issues to hold staff accountable for successful results.
  • Strong collaboration with the Legal and Regulatory teams as well as CEO, CFO, and other stakeholders during management of quality and compliance Crisis.
  • Performed internal and external quality audits and facilitated corrective actions.
MedData - CORPORATE COMPLIANCE, AUDITS AND EDUCATION DIRECTOR
City, STATE, 10/2011 - 02/2014
  • In this newly created position, reported directly to MedData’s chief medical officer and responsible for providing ongoing documentation, training, and education to MedData’s clinical and coding staff to ensure operational compliance and optimal reimbursement.
  • Overseen and monitored federal and state intermediary agencies documentation and coding policy changes that affected emergency medicine and other various medical specialties for which MedData bills on behalf of its clients.
  • Overseen 121 employees and 3.5 million budgets in driving process improvements throughout the organization, as well as improving productivity performance of workflow processes, policy and regulatory guidelines assurance, billing, risk management and client/staff education and training.
  • Reduced incidence of governmental investigation audits by 30% over three years, while case load increased by 55% for the same time period.
  • Audit medical claims to identify unlawful or incorrect Medicare billing and payments.
  • Performed all high-level risk management client audits, presented findings, recommendation to mitigate fraud and abuse of coding, and billing.
  • Assured effective tracking and trending of department performance and quality indicators, focus management on those metrics and actions across the organization and make improvements and adjustments as required.
  • Lead significant quality issues.
  • Hands on” with the issues, made appropriate recommendations, developed plans to resolve identified gaps in controls, communicated the plans and progress to the organization.
  • Collaborated with the functional heads across the company; created an accountable and quality-based culture.
  • Educates and trains employees as to their impact in the quality management system.
  • Provided industry expert Jessica
  • Claire Résumé - Page 3 strategic input to the annual planning and budgetary process by working with finance and senior management, ensuring timely, effective use of resources.
  • Conducted over 200 group practice physician documentation risk management education-training sessions and improved overall revenue enhancement for clients by 28% as compared to previous period.
  • Developed training module to monitor and manage HIPAA, Privacy & Security compliance training company-wide; with an average of 12% decrease in reported breech incidents from previous time period.
  • Reported and prepared detailed reports to the company’s compliance steering committee on a quarterly basis.
  • Developed a widely successful ICD-10 coding and documentation “readiness” algorithm for coding and clinical associates.
MBI Solutions - MEDICAL CODING AND PHYSICIAN PERFORMANCE DIRECTOR
City, STATE, 10/2005 - 11/2011
  • Handled complex coding algorithms, staff training, ensuring compliant and optimum coding requirements were met, monitored physician E/M coding curves and utilization of diagnostic services to effectively manage compliance and mitigate audit risk.
  • Set compliance revenue enhancement expectations by ensuring quality coding objectives with state, federal and payer regulations.
  • Continuously identified and helped drive through improvements with established coding, documentation requirements, processes, and procedures.
  • Successfully overseen more than 48 employees with 300,000 budgets for staff payroll, development, and training, drove productivity, managed workflow efficiencies, client relations, and developed clinical and coding educational tools and provided training to both clinical and coding staff.
  • Planned and implemented internal coding audit programs for more than 45 clients, developed policies to ensure compliant coding, and billing across clients.
  • Developed, implemented, and managed annual enterprise risk assessments along with organization action plans to mitigate areas of risk as client liaison.
  • Assisted in successfully facilitating the integration of health information management coding business objectives into IT product development initiatives.
  • Maintained and monitored coding staff productivity and quality standards for all coding personnel.
  • Ensured coding staff applied correct ICD-9, CPT, HCPCS codes and modifiers when applicable based on supporting provider documentation for optimum reimbursement and compliant coding.
  • Established and maintained good working relations with client stakeholders and key leadership, colleagues, and all subordinate staff.
  • Communicated professionally and effectively with physicians and group practices regarding documentation and federal/state regulatory guidelines.
Accomplishments
  • Performed risk assessment for a hospital system and identified process breakdowns in the hospital billing, collections, and cash posting processes, and implement innovative solutions to address new issues that arise.
  • Discovered population of aged accounts that needed resolution which helped relieve A/R by $4M. Implemented payer escalation process with top insurers resulting in payments of $2M.
  • Managed project timelines and ensuring that clients generated significant value from partnership with the Advisory Board
  • Educated executives and staff on ICD-10, clinical documentation, Risk Adjustment Coding, RAC programs, and revenue impact and enhancement topics; identified areas of opportunity and risk to prioritize strategies within long-term plan.
  • Performed detailed ICD-10 and CPT coding and reimbursement audits with deliverables and remediation to client coding staff from both professional/physician and an outpatient hospital perspective.
  • Evaluated clinical and coding practice operations of a medical practice. Developed and implemented action initiatives and streamlined processes and provided remediation services that significant decreased compliance risk and improved revenue enhancement.
Affiliations
  • Phoenix University, Elected Board Member of Honor Society, 2020
  • American Academy of Professional Coders (AAPC), Recognition for Expertise and Commitment to Professional Coding Association, 2019
  • Who’s Who, Awarded Expert in Healthcare Management Recognition, 2017
  • American Business Women’s Association (ABWA), 2017
  • President of American Academy of Professional Coders (AAPC) Dayton Local Chapter, 2010

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Resume Overview

School Attended

  • Phoenix University
  • Phoenix University and Corllins University

Job Titles Held:

  • REGULATORY HEALTHCARE COMPLIANCE AUDIT MANAGER
  • CORPORATE COMPLIANCE, AUDITS AND EDUCATION DIRECTOR
  • MEDICAL CODING AND PHYSICIAN PERFORMANCE DIRECTOR

Degrees

  • PHD of Science
  • Master of Science

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