Experience

KelseyCare Advantage

• United States
• Insurance
• 1 - 100 Employee

• Supervisor Risk Adjustment and Quality Assurance

  • Feb 2021 - Present

• Senior HCC Coding and Quality Assurance Specialist

  • Oct 2017 - Feb 2021

  Audit clinical documentation for HCC, HHS-HCC/ICD-10 coding compliance; communicate with physicians for feedback, documentation improvement, and education. Perform physician documentation and coding audits. Research clinical signs, symptoms, and treatment of diseases. Prepare and present group educational sessions, including physician education. Preform specials audits (RADV, Apixio, HEDIS).

• HCC Coding and Quality Assurance Specialist

  • Jul 2016 - Oct 2017

  Audit clinical documentation for HCC, HHS-HCC/ICD-10 coding compliance; communicate with physicians for feedback, documentation improvement, and education. Research clinical signs, symptoms, and treatment of diseases. Prepare and present group educational sessions. Preform specials audits (RADV, Apixio, HEDIS).

• HCC Coding Compliance Assistant

  • Sep 2015 - Jul 2016

  Audit charts for correct HCC, HHS-HCC/ICD-10 coding by all providers; identify coding problems and opportunities. Audit clinical documentation for HCC/ICD-10 coding compliance; communicate with physicians for feedback, documentation improvement, and education. Research clinical signs, symptoms, and treatment of diseases. Maintain knowledge of HCC and ICD-10 coding/documentation updates.



Kelsey-Seybold Clinic

• United States
• Hospitals and Health Care
• 700 & Above Employee

• Quality Assurance Analyst - Claims

  • Jun 2010 - Sep 2015

  Perform daily internal audit of claims to insure accuracy and timeliness of claims processing. Identify trending errors and work with management to coordinate in-service training programs, as well as documentation for processing support. Compile monthly audit results. Perform focus audits when trending issues are identified or as needed. Perform all new employees training for Claims and Preprocessor Analyst. Perform daily internal audit of claims to insure accuracy and timeliness of claims processing. Identify trending errors and work with management to coordinate in-service training programs, as well as documentation for processing support. Compile monthly audit results. Perform focus audits when trending issues are identified or as needed. Perform all new employees training for Claims and Preprocessor Analyst.

• Facility Claims Analyst

  • Nov 2008 - Jun 2010

  Adjudication of complex facility claims including hospital, DME, home health services, and skilled nursing, as well as the professional claims. Perform DRG pricing methods, Outpatient Prospective payment system mechanics (OPPS) and Contractual Payment Rates. Conduct pre/post analysis of high dollar claims and present summary to management. Adjudication of complex facility claims including hospital, DME, home health services, and skilled nursing, as well as the professional claims. Perform DRG pricing methods, Outpatient Prospective payment system mechanics (OPPS) and Contractual Payment Rates. Conduct pre/post analysis of high dollar claims and present summary to management.

• Claims Analyst

  • Nov 2007 - Nov 2008

  Adjudication of complex medical, dental, and facility claims for HMO members while maintaining minimum requirement for production and accuracy. Verification of various payment methods including case rates, Usual and Customary Fee Schedules, as well as Contractual Fee Schedules. Adjudication of complex medical, dental, and facility claims for HMO members while maintaining minimum requirement for production and accuracy. Verification of various payment methods including case rates, Usual and Customary Fee Schedules, as well as Contractual Fee Schedules.