Risk Adjustment Coder Auditor Resume Example

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Jessica Claire
, , 100 Montgomery St. 10th Floor (555) 432-1000,
  • Knowledge of Risk Adjustment and Hierarchical Condition Categories (HCC) and Medicare Advantage reimbursement
  • Task-oriented and ability to meet designated deadlines and productivity standards
  • Excellent understanding of medical terminology, disease process and anatomy and physiology
  • Excellent understanding of ICD-10-CM coding classification
  • Excellent understanding of CPT/HCPCS coding
  • Medicaid, Medicare and Commercial business products knowledge/experience .
  • Proficiency in Microsoft Word, Excel and SharePoint
  • Knowledge of CMS-1500 – Health Insurance Claim Form.
  • Knowledge of federal and state guidelines on all coding systems and sponsored programs
  • Advanced knowledge of auditing concepts and principles
  • Ability to use independent judgment and to manage and impart confidential information
  • Strong oral and written communication skills. Excellent organization and problem-solving skills
Work History
05/2019 to Current Risk Adjustment Coder/Auditor Carecloud | Miami, FL,
  • Review outpatient medical record information on both a retroactive and prospective basis to identify, assess, monitor and document claims and encounter coding information as it pertains to risk adjustment and quality metrics
  • Ensure that the diagnosis codes for each chronic or major medical condition have been captured and submitted within the permitted timeframe
  • Conducts physician chart audits to identify incorrect coding, prepares reports of findings and any compliance issues. Audits performed for both provider coding accuracy and documentation support as well as coding teammate accuracy
  • Reports coding patterns identified within the audit process to the Manager, and identifies corrective measures to compliance problems
  • Maintaining current knowledge of coding guidelines and relevant federal regulations through the use of current CPT-4, HCPCS II, and ICD-10 materials, the Federal Register, and other pertinent materials
  • Assess adequacy of documentation of claims and query outpatient provider claims to obtain additional medical record documentation or to clarify documentation to ensure accurate and appropriate coding
  • Interacts with coding teammates to deliver coding audit findings, discuss corrective measures and any necessary training required, and reports findings back to Coding Manager
  • Performs related work and projects as required
06/2017 to 05/2019 Medical Coder Greater Atlanta Women’s Healthcare | City, STATE,
  • Reviewed outpatient records and interpreted documentation to identify all diagnoses and procedures.
  • Abstracts clinical information from a variety of medical records and assigns appropriate ICD 10 CM and/or CPT codes to patient records according to established procedures
  • Ensure codes are accurate and sequenced correctly in accordance with government and insurance regulations
  • Follow up with the provider on any documentation that is insufficient or unclear
  • Communicate with other clinical staff regarding documentation
  • Search for information in cases where the coding is complex or unusual
  • Receive and review patient charts and documents for accuracy
  • Review the previous day's batch of patient notes for evaluation and coding
  • Ensure that all codes are current and active
06/2015 to 06/2017 Medical Coding Reviewer Change Healthcare | City, STATE,
  • Perform member and provider interviews, and review medical documentation as needed
  • Gather and analyze data and information gathered to determine behavior and understand provider/scheme at issue
  • Utilize appropriate documentation and tracking controls in the case tracking system to ensure compliance and audit ability requirements are met
  • Apply knowledge of coding guidelines to determine validity of aberrances
  • Gather all relevant facts to articulate behavior through an Investigation Summary and compliance package. Communicate clear rationale for investigation processes and outcomes to Client, Regulator and stakeholders
  • Collaborate with a variety of external sources to identify current and emerging patterns and schemes related for FWA to ensure additional TIP submission
  • Coordinates research and responds to system inquiries and appeals.
10/2013 to 05/2015 REMOTE CODER/Medical Biller, Accounts Receivable GEORGIA STATE HEALTH | City, STATE,
  • Reviewing and following up payment denials, contacting insurance carriers for payment resolution, filing appeals, submitting insurance claims to clearing house or individual insurance companies, retracting claims, and processing write offs/adjustments for non-payable charges according to payer contract.
  • Analyzes and interprets the medical record in its entirety to ensure accurate, complete and consistent selection of diagnoses and procedures to assure the production of quality healthcare data and accurate facility payment.
  • Applies understanding of basic anatomy and physiology to interpret clinical documentation and identify applicable codes.
  • Utilizes resources and reference materials (e.g., on-line sources, manuals) to identify appropriate codes and reference code applicability, rules and guidelines.
  • Enter information necessary for insurance claims such as patient, insurance ID, diagnosis, treatment codes, modifiers, and provider information. Ensure claim information is complete and accurate.
  • Prepare appeal letters to insurance carrier when not in agreement with claim denial. Collect necessary information to accompany appeal
  • Check insurance payments for accuracy and compliance with contract discount.
Expected in | Medical Coding American Academy of Professional Coder CPC, AAPC, GPA:
Expected in Emory Clinic | Certification of Electronic – Medical Billing, Healthcare Emory Healthcare, Atlanta, GA GPA:
Expected in 4/2000 High School Diploma | Eastside High School, The Galatians Group, Inc, Gainesville, College Park, FL, GA GPA:

Medical Coding Program

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Resume Overview

School Attended
  • American Academy of Professional Coder CPC
  • Emory Healthcare
  • Eastside High School, The Galatians Group, Inc
Job Titles Held:
  • Risk Adjustment Coder/Auditor
  • Medical Coder
  • Medical Coding Reviewer
  • REMOTE CODER/Medical Biller, Accounts Receivable
  • Emory Clinic
  • High School Diploma

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