As a QA/Coder/RN, I specialize in utilizing ICD-10 coding and OASIS assessments for Home Health Medicare patients, ensuring accurate and supportive documentation for precise reimbursement per Medicare guidelines.In my role, I translate patient records into codes used for billing, insurance reimbursement, and medical research. My daily tasks include reviewing medical records, analyzing patient charts for accuracy, and scrutinizing medical records, doctor's notes, and other patient information. I also confirm treatments with medical staff and identify any missing information.Key responsibilities include:Assigning codes to diagnoses, procedures, and evaluation and management services to ensure comprehensive medical records.Ensuring that all codes are accurate, properly sequenced, and comply with federal regulations and insurance standards.Following up with field nurses on any documentation that is insufficient or unclear.Communicating with other clinical staff regarding documentation requirements and improvements.Skills:Attention to DetailMicrosoft OutlookHCSD ICD-10Electronic ChartingQuality AssuranceCase ManagementKantimeCollaborative Problem SolvingHCS-OASISCisco Webex MeetingsMedical CodingRegistered NursesMicrosoft TeamsMicrosoft Office

As a QA/CODER/RN:ICD 10 coding and OASIS assessments for Home Health Medicare patients to ensure appropriately coded and supporting documentation for accurate reimbursement per Medicare guidelines. Collaborate with the assessing clinician for coding and OASIS recommendations

Assessed need for, ordered, obtained and interpreted appropriate lab test.Ensured HIPPA complianceLiaised between patients and physicians to ensure patient comprehension of treatment plans.Pharmacological and non-pharmocological management and treatment of various disorders and diseases.Processed monthly reports for department performance.Developed and implemented nursing care plans.Followed infection control procedures.Case management of assigned patients in accordance with agency policies and procedures.Coordinate care for a team of patients as assigned by management.

As RN case manager:Performed start of care assessment, Transfer and discharge along with OASIS Compliance.Provided patient care according to physician orders.Reported changes in patient's condition, carryout physicians order and follow up with resultsPerformed administrative duties such as: completing medical forms, reports, evaluations, studies, charting, etc.Provided direct nursing care to patients.Completed accident/incident/ infection reports.Participated in employee performance evaluations.Attended case conference on weekly basis.Admitted, transferred, and discharged patients as required.

As an LVN:Daily in home visits to perform assessment, observation, charting, changes in condition and taking any necessary actions to maintain proper care protocols.Obtains patient vital signs, including pulse, blood pressure, temperature, and respiration.Assist in evaluation in patients responses to care.Administer medications as per plan of care.Collaborate with an interdisciplinary team to establish and implement patient care strategies.Prepares specimens for lab.Reviews and documents in medical charts.Provides routine wound care for patients.Communicates with patients and their families.

LVN Nurse:Plan and manage patient care according to each patient’s needs.Interviews patients and record their medical history and physical condition.Obtain patient vital signs, including pulse, blood pressure, temperature, and respiration.Provided routine wound care for patients.Observed patients’ health.Review and documented medical charts.Communicates with patients and their families.Administers medications.Provided wound care.Assisted with patient comfortOther duties as assigned.