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Yyyyyy x. yyyyyy

18 Talister Ct. Xxxxxx, XXXXXX xxxxxx xxx-xxx-xxxx


Executive Profile


Focused, adept professional with a proven background in healthcare administration, policy, compliance and customer service, Works diligently to surpass organizational objectives and customer service expectations. Creates and introduces standardized policies and practices. Demonstrated ability to communicate effectively with individuals and groups at all levels. Currently seeking a role that will allow for leverage of skills and offer opportunities for advancement.


Selected Highlights


  • Suggested policy amendments based on conducted research of policies, procedures and regulations (United Health)
  • Evaluate proposed, modified or new legislation to determine impact on quality measurement and public reporting (United Health)
  • Work collaboratively with other coders and providers to advance and maintain coding processes (United Health)
  • Aided in continuous quality improvement processes to identify coding training needs and ensure timely (Cigna)
  • Worked in conjunction with other coders and providers to improve and maintain processes (Cigna)
  • Attended coding educational seminars to stay informed of coding certification trends (AUA)
  • Read various coding publications and partook in online forums to stay apprised of coding developments to share across the rest of the department in order to develop more innovative practices (AUA)
  • Actively played a role in multi-disciplinary quality and service improvement teams, as well as in meetings and on committees to represent the department and hospital during community outreach (Medstar)
  • Crafted and set forth training processes for new hires and temporary employees; trained both new and existing staff extensively on how to appeal insurance denials (Medstar)
  • Strengths include medical billing, coding, training, leadership, supervising, account management., strategic planning, analysis, research and evaluation methods, among others
  • Exhibits commitment to supporting employers operational and staffing needs by managing ad-hoc projects as requested


Professional Synopsis



Research Medical Coding Analyst-Medicare Policy and Research (2014 Present)

  • Deliver support for inquiries related to Medicare Advantage guidelines with a focus on Payment Integrity efforts
  • Develop and assess methodologies and algorithms that allow for noteworthy comparisons across the company
  • Revitalize the Medical Necessity Review program by determining and researching areas of vulnerability in the Medicare program specific to billing and Medical Necessity Coverage guidelines
  • Understand and explain complex Medicare rules to internal front-facing clients within member and provider communities
  • Handle provider reimbursement and medical policies to ensure the proper claims settlement
  • Evaluate billing performance to confirm optimal reimbursement while adhering to regulations that prohibit unbundling and other questionable practices
  • Draft reports for periodical review by clinical staff; identify unbilled charges due to inadequate documentation
  • Emphasize to physicians and medical staff the importance of medical record accuracy



Certified Professional Medical Records Coder (2013-2014)

  • Managed hospital records as it relates to reimbursement, research, and compliance with federal regulations
  • Processed records according to diagnosis, operation and procedure on a concurrent basis; found and documented discrepancies
  • Maintained updated knowledge of medical service coding and guidelines; monitored accuracy and compliance of documentation
  • Communicated with medical staff at varying levels regarding the relevance of medical record documentation and coding precision
  • Recognized inefficiencies in physician billing and coding; rectified as needed to enhance encounter capture



Certified Professional coder/Trainer (2012-2013)

  • Staffed the Coding Hotline to ensure delivery of prompt and precise answers to urology coding questions
  • Played a key role in educating leaders, members and managers on coding, reimbursement and payer policies

Yyyyyy x. yyyyyy



Certified Professional coder/Trainer (Continued)

  • Researched and replied to urologic, quality coding, reimbursement and policy inquiries from members, staff and others
  • Assisted the Practice Management Department staff with educational product and seminar logistics
  • Researched and authored articles that were featured in AUA coding publications
  • Maintained a library of current coding reference materials, for use in researching received questions



Insurance Specialist-Appeals/Denials Team (2010-2012)

  • Assumed complete responsibility for auditing employees at 100%; determined accounts that required appeals and processed each within 15 days of receipt thus ensuring all were completed within payer statute limitations
  • Completed outpatient appeals of no less than 42 accounts per day
  • Reviewed account to determine action required to expedite payment and resolve delinquency
  • Consistently reviewed accounts by utilizing all resources to obtain claims statuses and process accounts in an efficient manner
  • Founded facility contacts to secure information vital to the appeals process
  • Notified management in instances when a payer denial trend was discovered
  • Received daily workload of appeals via SMS ad hoc reporting; printed all reports daily and processed each in alignment with set departmental standards
  • Reported backlogs or potential issues by reporting them to supervisory personnel as soon as possible
  • Followed up daily with insurance companies regarding any outstanding appeals; ensured each was correctly processed, that all overturns were secured, and that receipt of payment from insurance companies were followed up on daily
  • Retained knowledge of UB-92 and other mandatory state billing and filing forms
  • Reviewed online claim submissions and reconciled them daily to comply with CPT, HCPCS and ICD-9 coding requirements
  • Led mandatory training in applying the SMS Patient Accounting, Patient Management and Receivable Workstation applications, as well as department orientation, e.g. reviewing procedures and standards


Earlier Experience


Medical Billing A/R Supervisor-Physicians Billing, Medstar Health, Xxxxxx, XXXXXX, 2006-2010

Outpatient Assistant/Billing Clerk, Georgetown University Hospital, Washington, DC, 2005-2006

Medical Billing Supervisor, Nexmed Systems (Integra), Gaithersburg, XXXXXX, 2002 2005


Education & Credentials


Masters of Business Administration, Health Services Administration, Strayer University, 2015

Masters of Healthcare Administration, University of Phoenix, 2013

Bachelor of Science, Healthcare Administration, University of Phoenix, 2012

Associates of Arts, Healthcare Administration, University of Phoenix, 2009

Certified Professional Coder (CPC), Coding Academy of America

Certified Professional Compliance Officer (CPCO), AAPC

ICD-10 Certification, AAPC



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