Medical Records Technician

Location:

Salisbury, NC

Posted:

August 17, 2014

Contact this candidate

Resume:

D. Andrew Bull

*** *. **** ********* ****. Objective

STE G, PMB # 215

Dedicated Medical Records Technician Coder with seven years of acute-care

Salisbury, NC 28147

hospital medical records coding experience. Completed full-time HIT program in

803-***-****

2006. Qualifications include:

Cell 704-***-****

************@****.*** Certified Professional Coder (CPC) certification

AAS degree in Health Information Technology

Expertise in ICD-9-CM, HCPCS and CPT coding

Knowledge of licensing, reimbursement and accreditation standards

Work Experience

Medical Records Technician (Coder)

7/2014 – Present, W.G. "Bill" Hefner VA Medical Center, 1601 Brenner Avenue

Salisbury, NC 28144 United States

Assign codes to documented patient care encounters (inpatient and

outpatient) covering the full range of health care services provided by the

VAMC. Patient encounters are often complicated and complex requiring

extensive coding expertise. Apply advanced knowledge of medical

terminology, anatomy & physiology, disease processes, treatment

modalities, diagnostic tests, medications, procedures as well as the

principles and practices of health services and the organizational structure to

ensure proper code selection. Select and assign codes from the current

version of several coding systems to include the International Classification

of Diseases-Clinical Modification (ICD-9-CM), Diagnostic and Statistical

Manual of Mental Disorders (DSM), Current Procedural Terminology (CPT),

and HCPCS. Adhere to accepted coding practices, guidelines and

conventions when choosing the most appropriate diagnosis, operation,

procedure, ancillary, or Evaluation and Management code to ensure ethical,

accurate, and complete coding. Monitor ever-changing regulatory and policy

requirements affecting coded information for the full spectrum of services

provided by the VAMC. Assist facility staff with documentation requirements

to completely and accurately reflect the patient care provided; provide

technical support in the areas of regulations and policy, coding requirements,

resident supervision, reimbursement, workload, accepted nomenclature, and

proper sequencing. Insure providers documentation is complete and

supports the diagnoses and procedures coded. Expertly search the patient

record to find documentation justifying code assignment based on an

expanded knowledge of the organization and structure of the patient record.

Utilize the facility computer system and software applications to correctly

code, abstract, record, and transmit data to the national VA database in

Austin. Orient and instruct new personnel and/or students from affiliated

health information or medical record technology programs, at the direction of

the supervisor, on unit operations, coding, abstracting, and use of an

electronic medical record. Work within a team environment; support peers in

meeting goals and deadlines; flexible and handle multiple tasks; work under

pressure; and ability to cope with frequently changing projects and

deadlines.

Selected Contributions:

Assist hospital pass JCAHO inspections by consistently meeting JCAHO

requirements.

Maximized reimbursement by ensuring accurate ICD-9-CM and CPT coding

and conducting regular quality audits of providers’ selected codes compared

to chart documentation.

Ensured records met quality and risk-management requirements by

participating in hospital chart review committee.

Rapidly mastered VistA and CPRS as well as the code selection

software (e.g., QuadraMed nCoder+ Suite for fast, accurate coding and

abstracting.

Medical Records Technician (Coder)

7/2011 – 7/2014, Landstuhl Regional Medical Center, Landstuhl, Germany

Select, assign and audit diagnostic and procedure codes to patient records for

a 150-bed, acute-care hospital. I am responsible for the following clinics:

Emergency Room, Family Practice, Orthopedics, Ophthalmology/Optometry,

Otolaryngology, Podiatry, Dermatology, Occupational Therapy, Physical Therapy,

Urology, General Surgery and Behavioral Health (Psychiatry and Child Adolescent

Psychiatry, Psychology and social Work). Manage chart completion (ICD-9-CM

and CPT coding/abstracting), chart assembly and analysis, patient admission and

patient information privacy/security. Act independently to plan, organize, direct and

control areas with emphasis on data validation, analysis and generation of reports

associated with the facility's Health Information Management Coding Compliance

program. Provide support and education on documentation issues and assist with

the development of guidelines for data compatibility, consistency and monitoring

for compliance to improve the quality of clinical, financial and administrative data to

assure that every part of the information is completely documented and supported.

Perform quantitative and qualitative review and analysis of heath records and

encounter information both concurrently and retrospectively, to ensure

documentation in both is accurate, consistent, complete and assigned codes can

be supported by the documentation.

Selected Contributions:

Helped hospital pass JCAHO inspections by consistently meeting JCAHO

requirements.

Maximized reimbursement by ensuring accurate ICD-9-CM and CPT coding

and conducting regular quality audits of providers’ selected codes compared

to chart documentation.

Ensured records met quality and risk-management requirements by

participating in hospital chart review committee.

Rapidly mastered Armed Forces Health Longitudinal Technology Application

(AHLTA) and 3M Coding Compliance Editor (CCE) for fast, accurate coding

and abstracting.

Coordinate and assist the development of standardized, system-wide

guidelines, procedures and compliance education materials for coding and

abstracting to meet the rules and regulations of government health

programs, VA and other external entity requirements and payers.

Medical Records Technician (Coder)

8/2010 – 7/2011, McDonald Army Health Center, Fort Eustis, VA

Select, assign and audit diagnostic and procedure codes to patient records for

an acute-care hospital. I was responsible for the following clinics: Emergency

Room, Ophthalmology/Optometry, Otolaryngology, Dermatology, General Surgery

and Behavioral Health (Psychiatry and Child Adolescent Psychiatry, Psychology

and social Work). Manage chart completion (ICD-9-CM and CPT

coding/abstracting), chart assembly and analysis, patient admission and patient

information privacy/security. Act independently to plan, organize, direct and control

areas with emphasis on data validation, analysis and generation of reports