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Risk Adjustment Audit and Education Manager Resume Example

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RISK ADJUSTMENT AUDIT AND EDUCATION MANAGER
Professional Summary

Risk Adjustment Audit and Education Manager with over thirty years experience in healthcare and over twenty years in coding, auditing and education. The past thirteen years I have been heavily responsible for the execution and oversight of risk adjustment audit and education projects by enhancing communications with physician groups and providing ideas to better service and increase the risk adjustment scores especially with the expansion of telehealth during the Public Health Emergency. In addition, I am deeply involved in the HHS-RADV for the Affordable Care Act by managing an audit team that provides all the clinical documentation to the IVA for three states. I keep abreast of everchanging federal guidelines and developments by following the, Center for Consumer Information and Insurance Oversight (CCIIO) communications and REGTAP webinars. My business focus is currently on Medicare Risk Adjustment and the Affordable Care Act.

Skills
  • Strong knowledge of Medicare and Affordable Care Act Risk Adjustment, including technical requirements as well as challenges the health plan and provider may have in meeting reporting requirements
  • Understanding of applicable CMS Medicare Part C & D reporting requirements including manuals, review guides and Code of Federal Regulations
  • Ability to interact with internal and external customers at all management levels
  • Strong problem solving ability and a customer centric focus
  • Team focused with an attitude of group achievement as the primary goal
  • Highly organized with a strong attention to detail
  • Demonstrates leadership and management skills
  • Effective collaboration skills and experience
  • Adept in working across a heavily matrixed organization
  • MS Office proficiency
  • Strong oral and written communication skills, including presentation skills
  • Ability to work in a virtual office and virtual teaming experience
  • Credentials: Certified Professional Coder (CPC) Certified Professional Compliance Officer (CPCO) Certified Compliance Officer (CCO) Certified Coding Professional (CCP)
Work History
Risk Adjustment Audit and Education ManagerCompany Name - City, State07/2008 - Current
  • Assist the Leadership teams at the regional and national level for one of the largest non-profit healthcare organizations in the nation, Kaiser Permanente in the Mid-Atlantic states (MAS).
  • Provide in-depth knowledge of Risk Adjustment Documentation and coding both for Medicare Advantage and the Affordable Care Act.
  • Represent MAS as the Risk Adjustment (RA) Audit subject matter expert for the regional on all National Compliance and Revenue Integrity calls to support any decision making.
  • Manage the RA audit team during the yearly Medicare Advantage and Affordable Care Act Risk Adjustment Data Validation audits.
  • Manage the Health Plan audit team for the yearly Healthcare Effectiveness Data and Information Set (HEDIS) to support the medical group's National Committee for Quality Assurance (NCQA) review.
  • Develop the Corrective action plan including training material for Hierarchical Chronic Condition (HCC) education for providers post regulatory audits.
  • Oversee the surgical coding team in Epic using charge entry, Transaction Inquiry, work queues, and hospitals portals.
  • Represent the coding and education teams during Epic router or work-queue development and program edit strategies.
  • Monitor the Epic work-queues to determine if there is a need to collaborate with the Health connect analyst teams to make any changes dependent upon the organizations changing policies, benefits or new services.
  • Delivered wide variety of courses focused on multiple and varied specialties, for the auditors to include Risk Adjustment, the New E/M guidelines for 2021 and internal Independent Development Plans, team building topics to enhance communication, team cohesion and group performance.
Owner/ManagerCompany Name - City, State06/1999 - 03/2003
  • Recruited, hired and trained initial personnel, working to establish key internal functions and outline scope of positions for new organization.
  • Reduced budgetary expenditures by effectively negotiating contracts for more advantageous terms.
  • Managed day-to-day business operations, including accounting, finance, HR, marketing and public relations.
  • Managed certified coder team for coding and billing functions.
  • Effectively communicate with a diverse group of physician specialists and support staff.
  • Trained staff in front end operations and coding office functions, Medicare and Medicaid billing processes, patient and insurance collections, recovery of outstanding A/R, compliance based chart review, assessment, and audits.
  • Assisted providers with insurance credentialing.
Office and Surgical AssistantCompany Name - City, State03/1990 - 06/1999
  • Office Assistant duties included patient care, surgical scheduling assist in office surgeries as well as surgeries in the operating room, coding, insurance authorization, and all front and back office duties.
  • Maintained accurate records of patient care, condition, progress and concerns.
  • Performed all in-office patient triage care in include, blood glucose levels, change sterile dressings, vitals, and minor office procedures.
  • Also, collected patient information medical history, drug history, complaints and allergies for provider visits.
  • Surgical Assistant; work with surgeons as a circulating assistant in surgery.
  • Provided pre- and post-operative care.
  • Maintained a clean, healthy and safe environment.
  • Supported duties for diagnostic and technical treatment procedures, such as setting up and operating special medical equipment and apparatus.
  • Arranged supplies and instrumentation to meet needs of individual surgeons and enhance team efficiency.
  • Kept views unobstructed by retracting, sponging and suctioning surgical sites.
  • Applied antiseptics and sterile dressings to cover surgical locations and boost healing.
  • Obtained coding credentials and supported the multi-specialty surgeons departments by coding their evaluation and management (E&M) services and invasive surgical procedures from operative notes.
Education
Technical Diploma: Medical And Surgical AssistantGalen College Of Medical And Dental Assistants - City, State03/1990
  • Graduated in Top of Class
  • Coursework Anatomy, Physiology, Medical terminology, pharmacology, phlebotomy, Surgical assisting, Patient care and Office Administration
Technical Diploma: Health Sciences And Legal CourseworkCollege Of The Sequoias - City, State
  • Coursework in Pre Nursing program: Anatomy, Physiology, Chemistry, Trigonometry, English Literature, and Paralegal coursework.
High School DiplomaExeter Union High School - City, State06/1984
Accomplishments
  • Developed a Risk Adjusted audit team to specialize in federal and regulatory audits.
  • Received accolades from the Kaiser Permanente National Compliance Office for completion of record submission for a federal audit prior to deadline.
  • The Kaiser Permanente Mid-Atlantic States had the highest number of records for submission during that time period.
  • Decreased the claims review error rate from 42.10% in 2003 to 2.26% in 2007 by means of training and education at Howard University.
  • Exceeded the 95% customer service benchmark required at Howard University.
  • Received high approval from the Director of Quality Assurance for managing the Risk auditors, and completing the HEDIS review prior to the deadline.
Affiliations

American Academy of Professional Coders (CPC) (CPCO) ICD-10 Certified Professional Healthcare Institute of America (CCP) (CCO)

American Health Information Management Association Health Care Compliance Association

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Resume Overview

School Attended

  • Galen College Of Medical And Dental Assistants
  • College Of The Sequoias
  • Exeter Union High School

Job Titles Held:

  • Risk Adjustment Audit and Education Manager
  • Owner/Manager
  • Office and Surgical Assistant

Degrees

  • Technical Diploma : Medical And Surgical Assistant
    Technical Diploma : Health Sciences And Legal Coursework
    High School Diploma

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