CARLYN CANVASSER CPC

Chicago, IL ***** Phone: 312-***-**** Email: ac73b7@r.postjobfree.com

HEDIS / HCC Risk Adjustment Specialist

10+ years’ experience as a Licensed Medical Certified Professional Coder recognized by the American Association of Professional Coders. Extensive focus in healthcare Quality Initiatives, HEDIS, HCC Risk Adjustment, Clinical Documentation improvement and provider education. Expertise in ICD-9 and ICD-10, CPT and HCPCS, E/M abstraction and auditing. Adherence to HIPAA regulations, CMS coding guidelines, NCQA compliance and company policies Excellent leadership, written and verbal communication skills with innate ability to build rapport with providers, hospital staff physicians, and vendors. Proven record of success in time sensitive and detail-oriented tasks and projects. History of working successfully in remote, project management and contract roles.

• HEDIS • ICD-9 CM/ ICD-10 CM Coding • CPT and HCPCS Coding • Data Abstraction

• STARS • Managed Care and Commercial Plans • Quality Improvement Initiatives • Provider Education

• E/M • Medical Record Management • Medical Record Audits • Clean Claims

• IVA/ VDA/ RADV • Clinical Documentation Improvement • HCC Risk Adjustment • Appeals EXPERIENCE

HEDIS AUDITOR/ HCC RISK ADJUSTMENT AUDITOR

HEALTH DATA VISION INFORMATION SOLUTIONS, Senior Remote Auditor 2012- Present

Senior HEDIS remote abstractor and Over read Auditor of Hybrid Medical Record Review with regulatory compliance using advanced Medical Record Collection System software to abstract compliant patient information for multiple health plans.

Performed retrospective patient chart audits to evaluate the accuracy of diagnosis and validate legitimate claims to avoid penalties for inaccurate or inaudible data in accordance with industry standards and coding guidelines,

Assist with ongoing review process as directed by Senior Leadership to assure accurate application of CPT, ICD- 9/ ICD-10- CM, HCPCS codes are captured for all dates of service requested to meet client deliverables.

Identified incomplete cases needing additional clinical documentation, researched patient treatment, diagnosis and related procedures using coded data to produce compliant results.

Remotely reviewed thousands of patient encounters to substantiate codes are supported by providers documentation and entered findings into data base for HEDIS and HCC Risk Adjustment project including all code capture and plan specific guidelines for IVA and VDA audits.

Assigned validation event codes to identify when documentation in record is inadequate, ambiguous or otherwise unclear and request additional clinical supporting documentation.

Collaborate directly with Clinical Operations Team to help support updates to the design and the development of both the HEDIS and HCC Risk Adjustment coding workflow process and data collection software. HCC REMOTE CODER/ AUDITOR

OPTUM HEALTH, Chicago, IL August 2017 – October 2017

Validated progress notes for MEAT specific compliance and entered appropriate diagnosis coding into database utilizing the Centers for Medicare and Medicaid Services Risk Adjustment Data Validation guidelines.

Responsible for communication of identified quality issues concerning documentation validation pertaining to CMS-HCC Medicare and HHS-HCC market place methodology and ICD-9/ ICD-10 coding guidelines to providers.

Processed attestation sheets and progress notes from work queue according to department guidelines.

Provided clear communication through query to PCP on documentation not meeting standard of basic administrative components to an encounter progress note.

Ensured accuracy of diagnosis coding data entry by comparing outcome of diagnosis claims data to post validation entry and claims.

Participated in extensive training program maintaining 95% accuracy and exceeding departmental productivity standards on a consistent basis.

Review clinical documentation and report analytics to identify areas of opportunity for accurate assignment of all documented diagnosis and procedure codes

MANAGER OF QUALITY DATA ABSTRACTION

MERIDIAN HEALTH PLAN, Chicago, IL 2017

Provided oversight in the development, implementation, documentation and evaluation of clinical data abstraction initiatives surrounding HEDIS, IL withhold program data methodology for all Meridian Illinois lines of business.

Managed team of Data Abstraction Medical Record Field Reviewers and the development of the Illinois abstraction strategy and implementing processes to improve HEDIS medical record documentation, medical record review performance and medical record data integrity.

Ran daily manager reports of team production, provider compliance, quality of facilities to track audit progress and correspond with leadership on time management to ensure monthly, quarterly and yearly deadlines.

Accountability for all HEDIS / MRR related requirements and oversight of internal medical record data bases and quality assurance processes.

Responsible for abstractor training and corrective action, analysis of performance, identification of barriers, and implementation of improvement action plans.

Worked collaboratively with several departments implementing organization of HEDIS, Medicare Stars and Key Performance Improvement priorities.

Developed, communicated and implemented MRR best practices for medical abstraction process improvements to include EDI, EMR, and electronic data share and reduced cost of vendor services.

Assign provider attribution list to territory abstractor, organized and tracked return receipt and validity rate and productivity.

Created workflow and process for medical record collection, submission and validation.

Responsible for all Roadmap and audit communications and submissions.

Trained new and current staff on proper updates in Quality Measures per NCQA and CMS Coding Guidelines and compliant clinical documentation.

Perform decision making internal coder audits of medical record documentation as applicable with education feedback and training.

Provided Risk Adjustment and HEDIS education to providers and staff to ensure highest level of specificity and conditions accurately documented.

Review provider clinical documentation to assure the appropriate Evaluation and Management levels are assigned with correct CPT codes.

Efficiently worked with multiple providers and health plans to strategically retrieve relevant medical records, abstract compliant information, compile reports, and electronically upload or transfer data that maximized HEDIS rates for hybrid measures and resolved any issues that may have impacted results. HEDIS CODING QUALITY COORDINATOR

FAMILY HEALTH NETWORK, Chicago, IL 2013 - 2017

Directly responsible for state recognized improvement of quality metrics for largest fastest growing Managed Care Organization in Chicago, IL providing both Medicaid and Medicare services for over 300,000 members.

ICD-9-CM, ICD-10-CM, CPT, HCPCS, and HEDIS NCQA Subject Matter Expert responsible for creating internal and external training materials, Provider HEDIS coding reference and Required Authorization materials resulting in a statistically significant increase in rates, and reduction in claims and referral denials.

Educated providers on compliant clinical documentation and claims submission resulting in an improved reported composite rate of 59% and meet over 50th percentile with QSMIC goals of over 78% in 39 out of 50 measures with an increase of at least 1% in over 89 measures.

Responsible for rate calculation and financial payout calculation and reporting of over million-dollar medical pool for network of 3000+ providers for 2014, 2015 and 2016 Pay for Performance Quality Incentives.

Present yearly, quarterly and Quality analytics, variances, rates, monthly minutes, summary outcomes and observations to Board of Directors, Providers and Leadership Oversight Committees.

Validate, analyze and report data using predictive methodology based on individual member level of health risk, dependent upon accurate diagnosis coding with accurate identification of conditions to highest level of specificity.

Identify opportunities and actively participate in process improvements related to enhancing health plan quality and state specific projects to improve HEDIS scores, CMS Star Ratings and other metrics

Responsible for training and creation of education material for all responsible departments and providers to resolve solutions to denied claims and clinical documentation improvement and coding guidelines to improve compliance.

Integral part of creating strategy and workflow for Quality Mangers MRR best practices, including chase logic, oversampling, numerator negatives, exclusions, medical record abstractions, Inter rater reliability, appointment scheduling, and fax strategies.

Review clinical documentation to determine adherence to established government and third-party billing and compliance guidelines, AMA, CMS, NCQA, and coding policies.

Work with IT interface, data mart, supplemental and historical data to assist in QA of files for accurate compliance of eligible members for data warehouse.

Oversaw on going relationships with vendors and providers for all aspects of HEDIS program and Quality Improvement strategy.

Review claims process, appeals, grievances, research, resolve rejection issues and monitor claim denials with provider service reports

HCC RISK ADJUSTMENT CODER AND PIA PAYMENT INTEGRITY AUDITOR ALTEGRA HEALTH INFORMATION SOLUTIONS, Remote Part Time 2015

Extensive knowledge of medical billing, medical terminology and payment methodologies, including coding guidelines for ICD-9-CM and ICD-10-CM with demonstrated understanding of CMS HCC Risk Adjustment coding and data validation requirements

Proven clinical background in anatomy, physiology, pathology, medical terminology, and pharmacology

Abstracted pertinent information from patient medical records and assigned appropriate ICD-10-CM codes, creating and/or Rx HCC group assignments

Assigned flagged event codes when documentation in record is inadequate, ambiguous or otherwise unclear and request additional clinical supporting documentation

Remain current on medical coding guidelines and reimbursement reporting requirements and comply with the standards of ethical coding as set forth by the American Association of Professional Coders and American Health Information Management Association with adherence to official coding guidelines.

Demonstrated ability to understand clinical content of health records and utilize auditing skills related to coding quality and compliance

HEDIS FIELD AUDITOR

INSTAR HEALTH INFORMATION SOLUTIONS, Midwest Region 2012

Coordinated the development, implementation, documentation and evaluation of quality improvement initiatives throughout Midwest region to support QI projects, disease management programs, HEDIS, CAHPS and National Committee (NCQA), and PIP related activities.

Visited hospitals, physician’s offices, and provider sites to perform audits for Health Effectiveness and Data Information Set (HEDIS) projects. Developed and managed process for collecting and interpreting medical records to support hybrid reporting.

Established and cultivated effective working relationships with records managers, physicians and medical staff members to facilitate future data collection and record access.

Advocated to health plans ways to achieve solutions in HEDIS audits, risk adjustment, retrospective reviews, medical record keeping studies, performance improvement projects and other quality improvement initiatives developed by National Committee for Quality Assurance (NCQA).

Team lead regarding work flow process identifying gaps in core measures providing documentation improvement, management and abstraction solutions

Responsible for the development of multi state strategy and development of process to improve HEDIS medical record collection, medical record review performance and medical recorded integrity with accountability for all HEDIS and MRR related requirements

MEDICAL RECORD FIELD REVIEWER

OUTCOMES HEALTH INFORMATION SOLUTIONS, Chicago, IL 2011 - 2015

Responsible for end to end solutions improving performance as a Medical Record Collection Field Reviewer acquiring, auditing, and analyzing clinical documentation health care data for various healthcare organizations.

Traveled to assigned medical physician offices and hospitals working remotely throughout Midwest accessing various EMR / EHR systems to retrieve and review encounter documents from medical records for assigned projects and studies.

Reported directly to regional advocate to efficiently plan daily activities and confirm appointments, access to sight, contact and validity of chart assignments.

Provided 24-hour IT support, lap top computer equipment and portable scanner with software for onsite scanning of medical records and transferring files to secure file portal.

Completed extensive training testing and successfully maintained required above 95% accuracy and above average productivity of 75+ charts per day.

Maintained compliance and adherence to all HIPAA and associated patient confidentiality requirements.

Collected medical records for HCC Risk Adjustment, HEDIS and gaps of care to assist in organizing data to be accurately entered into database.

EDUCATION

Certified Medical Billing and Coding Specialist: US Career Institute, Ft. Collins, CO Bachelor of Science Degree in Retail Business: University of Arizona, Tucson, AZ Certified Professional Coder (CPC) American Association of Professional Coders (AAPC) Certified Professional Medical Auditor (CPMA)

National Alliance of Medical Auditing Specialists (NAMAS) Certificate TECHNICAL PROFICIENCIES

MS Office MS Excel MS PowerPoint MS Access Meditech McKesson 3M HSS QuadraMed EClinical Kareo

CureMD Epic Allscripts Cerner Athenahealth Nextgen Emdeon Verisk Qnxt Care Manager GE Healthcare Vital Care360 Practicefusion OptumInsight Nextgen Advandedmd Soapware Emdeon Valence Interqual ICARE MEDI EMD Vitera Meditab

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