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
Company NameRisk Adjustment Coder/Auditor //City, State//May 2019 to Current
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
Company NameMedical Coder//City, State//June 2017 to May 2019
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
Company NameMedical Coding Reviewer //City, State//June 2015 to June 2017
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.
Company NameREMOTE CODER/Medical Biller, Accounts Receivable//City, State//October 2013 to May 2015
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.
Medical CodingAmerican Academy of Professional Coder CPC//City
Emory Clinic - Certification of Electronic – Medical Billing, HealthcareEmory Healthcare//City, State
High School DiplomaEastside High School, The Galatians Group, Inc//City, State//April 2000
Resumes, and other information uploaded or provided by the user, are considered User Content governed by our Terms & Conditions. As such, it is not owned by us, and it is the user who retains ownership over such content.
How this resume score could be improved?
Many factors go into creating a strong resume. Here are a few tweaks that could improve the score of this resume:
American Academy of Professional Coder CPC
Eastside High School, The Galatians Group, Inc
Job Titles Held:
Risk Adjustment Coder/Auditor
Medical Coding Reviewer
REMOTE CODER/Medical Biller, Accounts Receivable
Medical Coding Emory Clinic - Certification of Electronic – Medical Billing, Healthcare High School Diploma
Create a job alert for [job role title] at [location].