- Expert in ICD-10-CM Diagnosis Coding and ICD-10-PCS Procedure Coding, with a strong adherence to Coding Guidelines.- Proficient in utilizing Coding Clinics to support and enhance coding accuracy.- Skilled in reviewing MS-DRG Assignment mismatches between CDI and Coding to ensure accurate classification and reimbursement.- Accurate assignment of Present on Admission (POA) indicators to reflect patient conditions.- Comprehensive review of Severity of Illness (SOI) and Risk Mortality (ROM) to support clinical documentation.- Established working relationship with CDI teams to address missing documentation and query needs effectively.- Committed to ongoing education and understanding in coding, anatomy & physiology (A&P), and pathophysiology to stay current with industry standards and practices.

- Analyzed and reviewed denied medical charges to identify coding-related issues and discrepancies.- Determined the root causes of coding denials, including diagnosis code mismatches, incorrect CPT codes, modifier problems, and coding errors.- Investigated and responded to insurance coding-related denials under Urgent Care and Multi-Specialty, addressing claim rejections, medical necessity denials, diagnosis code issues, appeals, and general coding error denials.- Corrected coding errors and discrepancies in denied claims, ensuring alignment with coding guidelines and regulations.- Assigned accurate diagnosis codes (ICD-10) and procedure codes (CPT/HCPCS) based on medical record documentation.- Prepared and submitted appeals with well-structured arguments to overturn coding-related denials and secure expected reimbursement, ensuring all necessary documentation was included.- Acted as a liaison between coding professionals, clinical staff, billing departments, and payers to resolve coding denial issues.- Communicated denial trends, root causes, and resolution strategies effectively within the organization.- Stayed current with healthcare regulations, coding guidelines, and payer policies to ensure compliance throughout the denial management process.- Assisted with internal and external audits related to coding and denial processes.- Identified areas where clinical documentation could be enhanced to support accurate coding.- Utilized Optum 360's Encoder Pro and Cerner to obtain the most accurate medical codes for proper billing and reimbursement.- Performed accurate analysis of medical records to obtain the appropriate sequencing and assignment of Evaluation and Management (E/M) codes, Current Procedural Terminology (CPT) codes, and International Classification of Diseases (ICD-10 CM) codes.- Maintained an acute focus on revenue integrity, auditing, and compliance with third-party payer requirements.

- Performed accurate analysis of medical records to obtain the appropriate sequencing and assignment of Evaluation and Management (E/M) codes, Current Procedural Terminology (CPT) codes, and International Classification of Disease (ICD-10 CM) codes.- Utilized Optum 360's Encoder Pro and Cerner to ensure the most accurate medical codes for proper billing and reimbursement.- Investigated and responded to insurance coding-related denials, including coding-related claim rejections, medical necessity denials, diagnosis code issues, appeals, and general coding error denials.- Collaborated with medical staff, physicians, payers, insurance providers, data entry, and billing companies to ensure successful denial resolution.- Identified and communicated trends in coding and billing, leading to educational opportunities for physicians.- Escalated potential compliance risk scenarios for the organization.- Accessed multiple systems and navigated through them to obtain information for denial resolution and documentation support for appeals.- Managed 40+ billing accounts with over 30 inpatient hospitals around the country using client systems such as EPIC, Cerner, eClinical Works, and Meditech.- Promoted billing accuracy by evaluating provider charges and updating patient insurance coverage.- Maintained an acute focus on revenue integrity, auditing, and compliance with third-party payer requirements.

- Managed 40+ billing accounts with over 30 inpatient hospitals around the country using client systems such as EPIC, Cerner, eClinical Works, and Meditech.- Investigated, analyzed, and audited over 120 daily claim rejections and denials from payers to consistently reduce aged receivables.- Promoted billing accuracy by evaluating provider charges and updating patient insurance coverage.- Maintained an acute focus on revenue integrity, auditing, and compliance with third-party payer requirements.

- Used 3M software and paper medical records to abstract 50+ acute inpatient behavioral health diagnosis and procedure codes, performing auditing reviews and producing monthly quality reports to reconcile clinical data and ensure coding accuracy and compliance.- Performed daily audits and filing of medical charts to ensure compliance with Health Insurance Portability and Accountability Act (HIPAA) and Personal Identifiable Information (PII) requirements.- Diligently provided ongoing training to team members and collaborated with management to develop innovative ideas that streamline internal medical coding processes.

- Strategically used eClinical Works and Cerner to accurately abstract medical codes from OB-GYN and GYN surgical charts, ensuring proper submission of claims electronically to insurance companies for reimbursement.- Reviewed the charge capture database to confirm accurate billing for a Federally Qualified Health Center (FQHC).- Communicated directly with physician offices for clinical documentation improvement, utilizing departmental tracking tools to document incoming complaints and resolutions, and analyzing internal inefficiencies.- Provided well-written and time-sensitive responses to members, providers, and third-party payers via Outlook or written letters to inform of claim or billing discrepancies.- Audited 25 coded charts daily to confirm accuracy and compliance.

- Spearheaded the revamp of the process for transmitting patient PHI for grievances and appeals, resulting in the implementation of uploading medical records into PDF files in Nuance and new workflows. This initiative reduced turnaround time for provider reviews from 3 business days to 1 business day, significantly decreasing the number of days for case closure.- Reviewed, researched, and resolved member and provider complaints to ensure satisfaction and compliance.- Managed data of grievances and appeals on applicable reports as part of the Healthcare Effectiveness Data and Information Set (HEDIS) production process.- Collaborated with the case management team to discuss claim findings, thoroughly followed up on pending claims to ensure timely processing, and created monthly updates for team meetings.

**Claims Adjudicator**- Researched and resolved complex inpatient/outpatient claims under the United States Government's 9/11 personnel health fund program, adjudicating 120+ claims per day using National Correct Coding Initiative (NCCI) claims processing compliance requirements.- Collaborated with management to gain override approvals, assisted in training new hires, and updated training Standard Operating Procedures.- Reviewed revenue cycle for billing errors and worked to resolve them in a timely manner.- Analyzed reporting metrics and performed root cause analysis to identify potential gaps in payments.

Independently examined and timely processed 250+ appeals cases per week using E-Clinical database and timely followed-up on all claim escalations through resolution.Determined medical necessity by utilizing guidelines, reviewing tools, conducting extensive research, and audit appeal issue(s), pertinent claims, and medical records to either approve previously denied claims for payment, or summarize and route denied claims to nursing and / or medical staff.Updated nine departmental training manuals to help meet business needs, interpreted policies, procedures, and benefit language to team members and providers.Liaison selected to attend internal meetings to gain additional knowledge of the Center for Medicare and Medicaid Services (CMS) guidelines, the National Committee for Quality Assurance (NCQA) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requirements and Local and National Coverage Determination Policies (LCD & NCD).

Improved customer satisfaction and increased accuracy by sending written correspondence to members and providers, explaining denials, and requesting additional medical documentation needed for payment.Met 30-day claim completion requirements by participating in claims workflow projects, such as processing dental claims, UB-04 and CMS 1500 claim forms with 50 or more lines.Increased efficiency and accuracy by thoroughly auditing claims for inaccuracies, correcting errors whennecessary, and paying or upholding claim denials.