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Coding and Charge Capture Specialist

DeSoto, TX, 75115
September 10, 2018

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* * * * . ************ • O V I L L A, T X * * * * 4

( 4 6 9 ) 658- 5 5 8 1 • Q B R OWNING1@GMAIL.C OM



Highly organized analytical professional with superior goal setting, decision-making, and problem-solving skills. Solid reputation for focus on quality care, community engagement, nurturing partnerships, and encouraging staff development. Accustomed to the integration of new health care delivery systems, restructuring of work, and increasingly complex regulatory environment. Extensive knowledge of medical billing and coding, and a documented track record of outstanding accounts receivable performance. Adept at managing personnel, finances, facility operations, and admissions while concurrently providing excellent residential care. Strong ability to identify, develop and sustain a network of people and other resources for tasks. Able to execute strategic initiatives in a methodical approach.


January 2017 – Present Molina Healthcare Inc. – Irving, TX

Delegation Oversight Specialist

Act as primary contact for providers and serve as liaison between the providers and the health plan

Work closely with the provider configuration department in monitoring and validating provider information is accurate in the core processing system

Perform comparative analysis of contracted provider’s data

Ensure the integrity of the provider’s data including data extraction, storage, manipulation, processing and analysis

Support business and management with clear insightful analysis on large data sets including data auditing, aggregation, validation and reconciliation

Handle project management in all aspects of delegation

Conduct annual credentialing/re-credentialing audits to evaluate licensed independent providers to ensure compliance with State, Federal, and National Committee for Quality Assurance standards

Assist in developing and implementing corrective action plans as non-compliant issues are identified through the oversight process

Develop and implement departmental tracking tools to insure timely issue resolution and compliance with all applicable standards

Develop and implement standard operating procedures for departmental training

Perform account management duties for 12,000+ delegated providers

Lead monthly Joint Operation Committee meetings with providers to evaluate outstanding issues and action items

Research the root cause for claims denial issues and provide resolution

Educate providers regarding policies and procedures related to Managed Care Organization standards, and referrals, claims submission, provider web site, EDI solicitation and problem solving October 2015 – January 2017 Molina Healthcare Inc. – Irving, TX

Senior Auditor (Grievance & Appeals)

Handled the timely execution of risk-based internal audits in accordance with the annual audit plan, as well as assisted with other audit matters and projects

Researched and reviewed the resolutions for the Complaints and Appeals department, and made recommendations to change the standard operation procedures while implementing new systems

Audited the work of the Complaints and Appeals Analyst/Specialist

Assisted the Management team in the development of an audit system that would track the progress towards the company’s improvement goals

Developed and implemented internal Procedures in accordance with standards, and requirements established by the Centers for Medicare and Medicaid

Created and prepared audit plan presentations for employee training and improvement opportunities 2

while developing, and implementing strategic audit documents to evaluate, and monitor their performance on key quality indicators

Implemented project plans for the ‘Grievance and Appeals’ audit process which included issue tracking, root cause for the resolution, and the escalation process for critical issues

Created metrics and status reports, to report progress against project objectives and milestones

Ensured successful completion of assigned audit engagements, from start to finish, inclusive of preplanning and wrap up activities

Applied risk and control concepts to scenarios encountered, and identified any potential issues

Communicated identified issues with senior management to ensure any potential concerns were addressed in a timely and effective manner

Applied the root cause analysis method to understand problems, make adjustments, and improve performance for provider issues

August 2009 – March 2015 HMS-Health Management Systems – Dallas, TX

Operations Quality Assurance Analyst II

Performed quality assurance checks for government and managed care deliverables, client quality standards for accuracy, timeliness, and values to claim audits for continuous revenue flow

Handled assign audits by researching and analyzing information

Worked closely with stakeholders to articulate quality standards for deliverables, by training and coaching them on meeting quality standards for on-going improvement methods

Reviewed and audited the final work product of multiple lines of business to ensure final deliverable met external clients’ quality requirements

Analyzed program deliverables for compliance with applicable statutory, regulatory, and contractual requirements

Assessed the input and output of data against SLA and compliance expectations.

Served as a liaison with project managers to solve edit issues, ensured deliverables meet client’s requirements through detailed review, and ensured client’s required documentation was current

Recommended processes and methods for streamlining/automating quality review processes to identify errors more efficiently

Served as one of the project leads on a HCPC/CPT code crosswalk coding project

Administrated data into Share Point, reviewed files within mainframe and crystal listing for defects

Audited and approved large data files submitted from HMS Cost Avoidance, Operations, and Recoupment teams

Recommended best candidates for employment, and assisted with orientation and training March 2006 – August 2009 Schumacher Group (EMBCC) – Dallas, TX

Insurance Analyst

Acted as medical billing, accounts receivable, and coding specialist for emergency room physicians

Reviewed emergency room physicians, and hospital managed care fee agreement for correct claims payment

Billed complied data provided by certified medical coders to insurance companies and billed members

Monitored and evaluated the effectiveness of the assigned physician’s revenue control plans by maximizing revenue and bringing to attention any issues

Used online application tools to gather and analyze data

Prepared quarterly revenue reports; documented and resolved any financial configuration issues by developing and maintaining the data integrity and accurate calculations

Worked directly with the insurance company, healthcare providers, and patients to get the claims processed by resolving billing edits and any issues that was holding claims from being processed

Audited physician and patient accounts by following policy and procedure issued by the organization

Ensured proper billing and coding was utilized by the review of medical documentation

Reviewed and utilized CMS and TMHP fee schedules for allowable medical procedures

Audited denial trends due to billing issues


Analyzed revenue reports by utilizing my knowledge of reimbursement methodology, coding, charge capture and charge reconciliation


Capella University – 2012

Degree: Master of Science in Healthcare Administration University of North Texas – 2009

Degree: Bachelor of Applied Science in Healthcare Management CERTIFICATIONS

Oracle SQL Certification (In Progress)

Project Management Professional (PMP) Courses

Certified Professional Coder Certification (CPC) Preparation Courses

Human Resource Certificate

Medical Claims Processor Certificate


AAPC (American Academy of Professional Coders) Member PROFESSIONAL TRAINING

HIPAA (Health Insurance Portability and Accountability Act) Knowledge

ICD 9, HCPC, Modifier, and Procedure Coding Knowledge ADDITIONAL SKILLS & COMPETENCIES

Microsoft Word PowerPoint Excel

Access Adobe Outlook

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