Customer Service Medical
Resume:
Valeda "Gail" Martinez, CPC-H
ICD-** Certified
**** ****** ***** *****, *********, CA 94513
acgh45@r.postjobfree.com
EXPERIENCE
San Francisco Health Plan, San Francisco Ca
Medical Management Coding Analyst
12/9/13- Present
. Supporting all areas of SFHP, the Medical Coding Analyst is
responsible for ensuring that the core administrative systems are
configured accurately and kept up-to-date for medical coding. He/she
provides coding guidance for benefit configuration as well as for the
Utilization Management, Contracting and Claims Departments. He/she
also performs business analysis and writes business requirement
documents, processes, policies and procedures as well as training for
the business. This is a key role for SFHP as we continue to meet the
continuous regulatory, compliance and industry changes.
. ESSENTIAL DUTIES & RESPONSIBILITIES
. Acts as the coding expert (ICD-9, ICD-10, 5010, CPT, HCPCS and Revenue
codes) for the organization.
. Involved in reinsurance and reimbursement activities, such as the Rate
Development Template (RDT) process.
. Participates in major code change projects, e.g., ICD-9 to ICD-10
conversion.
. Interprets existing and new contract codes, ensuring that codes are
accurately set-up on all systems.
. Participates actively in the Contract, Claims and Configuration (CCC)
team.
. Coordinates system changes related to Medi-Cal updates, participates
in business UAT and obtains approvals for go-live.
. Communicates coding changes to appropriate departments.
. Documents policies and procedures related to our management of medical
codes.
. Creates and produces new documents, presentations; responds to ad hoc
requests.
. Performs miscellaneous duties as assigned.
.
. INDIVIDUAL CONTRIBUTOR EXPECTATIONS
. Understands and supports the SFHP mission and its overarching business
goals and objectives.
. Acts with integrity, honesty and fairness, remaining mindful of the
duty of trust SFHP has to it employees, and to its providers,
employers and members.
. Able to balance a rapidly shifting workload and to deal effectively
with ambiguous circumstances while ensuring the timely completion of
work.
. Accepts and adapts to changes in SFHP policy, practice, procedures
quickly and positively and proactively supports his/her colleagues in
adapting to changes in the workplace.
. Contributes actively and effectively to team discussions, sharing
his/her knowledge and expertise willingly and collaboratively.
. Implements, monitors, utilize supports and communicates agreed upon
departmental performance competencies metrics.
. Identifies business process improvements that are aligned with and
supportive of SFHP business goals and objectives. Provides thoughtful
analyses and recommendations.
. Models professional behavior/conduct that remains in concert with the
SFHP culture and business values.
. CORE COMPETENCIES / KNOWLEDGE & SKILL REQUIREMENTS
. Strong analytical, problem solving, negotiation, collaboration and
communication skills.
. Extensive experience with ICD-9, CPT, HCPCS and Revenue codes.
. Detail oriented with problem-solving abilities.
. Ability to produce accurate and precise work, detect discrepancies and
resolve discrepancies all while meeting deadlines.
. Knowledge and appropriate application of English grammar including
composition, editing and proofreading skills.
. Documentation skills including business requirements, process flows,
policies and procedures and training materials.
. Proven ability to actively participate in several projects at the same
time.
. Strong client services orientation with emphasis on quality of
services, client support and responsiveness.
. Strong ability to influence without authority.
. Ability to work effectively, independently, and as part of a team.
. Ability to maintain confidentiality.
. Basic understanding of SFHP policies and procedures.
Contra Costa County, Martinez, CA
CDM - ER/Outpatient Coder-Account Clerk-Advanced Level- Patient Accounting,
HB 9/28/2011-December 2013
. Outpatient and Emergency Room coder for Contra Costa County, 20+
years.
. Inpatient and outpatient surgery coder for Contra Costa County in
1990.
. Adding Physican E/M codes, reviewing and updating physician E/M codes
from new to established for Medi-Care.
. Coding Radiology, CardioPulmonary and Pathology.
. Assigned diagnostic and procedural codes using the ICD-9-CM and CPT-4
coding classification system.
. Assign correct codes to procedures, lab, pharmacy and supplies
. Full time participation in Epic project Charge Master(CDM) from
9/28/11-Present.
. SME Epic project, Charge Description Master, Resolute Hospital Billing
attending HB off-site validation meetings as assigned.
. Assisting with Implementation Hospital Billing, Charge Masterr Go-Live
EPIC project.
. Member of Hospital Billing testing team before Go-Live.
. Successful testing to ensure charge codes are system ready for Go-Live
by assisting with project team for system support for Charge Master.
. At Go-Live, a member of the command center Hospital Billing Rev cycle
meetings as well as testing and implementation.
. At Go-Live identify departments at CCRMC with low Revenue, schedule
and attend face to face meetings with department heads to identify
problems with charging, charge codes, and Clinical staff Navigators.
. Train heads of Departments at CCRMC on Rev/Usage reports.
. Assist team in identifying charge codes needed on navigators in
various departments at CCRMC.
. Participates in systems analysis, design and implementation
. Advises and consults with application programmers during system
analysis.
. Attends and participates in professional group meetings and stays
current on new trends and innovations in the field of information
systems support and analysis.
. Before Go-Live update and maintain the charge master for Contra Costa
County Health Services.
. Create new charge codes for surgery, lab, pharmacy, diagnostic
imaging.
. Create new CCFA charge forms for finance, CCRMC outlying clinics.
. Calculating the correct amount CCC charges for various surgeries and
enter along with charge code into charge master.
Medical Record Technician- Patient Accounting, HB
8/2009-6/2011
w Applied ICD-9 diagnosis to outpatient and emergency room visits.
Assigned diagnostic and procedural codes using the ICD-9-CM and CPT-4
coding classification system,
w Reviewed medical records for documentation for billing issues;
(patient accounting).
w Responded to requests for information and answers questions from other
health care providers, patients, or other agencies/companies.
Health Plan Authorization Representative
2/2008 thru 8/2009
. Receive and enter prior authorization requests for medical services or
prescription drugs not the health plan drug formulary as well as
retroactive authorization, inpatient hospitalization, and appeal
requests.
. Respond to providers, members, claims, and member services inquiries.
. Review incoming authorization and appeal requests to determine if
supporting documents are submitted or available for a nurse or
pharmacist for clinical review and make a decision or to request
additional information as needed.
. Verify member eligibility.
. Accurately code each requested service and procedure.
. Process authorization requests within established timeliness
standards.
. Assist with determining if requested services are within the member's
scope of benefits, if prior authorization is required, and if the
requested service requires clinical review for medical necessity by a
Registered Nurse or Pharmacist or the Medical Director.
. Identify other payer sources and determine health plan primacy.
. Act as the liaison between clinical reviewers and providers/members.
. Inform providers and members of approval/denial/modification of
requests, appeal determinations via verbal and written communication.
. Maintain authorization and appeal documents in accordance with
regulatory agency requirements.
. Accurately prepare written notices and, as appropriate, include
applicable deductibles, co-payments, and benefits limitations.
. Generate written correspondence in the correct language as mandated by
regulatory agencies within regulatory timeframes.
. Collaborate and communicate with other CCHP units such as Member
Services, Membership Maintenance, and Claims units to ensure records
are updated and claims are paid correctly.
. Refer any complex complaints or inquiries to supervisor or appropriate
unit within the Health Plan to ensure timely and accurate response.
. Adhere to authorization guidelines of Federal and State agencies
governing health plans.
. Perform other duties and special projects as assigned, including, but
not limited to entering, monitoring, tracking, and generating reports
related to California Children Service referrals, specialized
programs, and specialty referrals.
Martinez Construction, Brentwood, CA
Account Clerk/Secretary/Office Manager 5/4/2005-
2/20/2008
Part-Time Account Clerk/Secretary/Office Manager 1/2000-
Present
w Manage accounting of an underground construction company.
w Write and maintain policies and procedure manual for various job
functions in the company.
w Ensure employees adhere to policies and procedures and CAL-OSHA
procedures to ensure safety.
w Knowledge and set up of QuickBooks for accounting functions.
w Document and reconcile Journal and general ledger entries, including
accounts payable and accounts receivable, account reconciliation,
balance sheet, vendor invoices, telephone bills, etc.
w Produce weekly and monthly accounting reports.
w Produce weekly and monthly cash flow reports.
w Cash handling and prepare deposits of cash and customer checks for
delivery and deposit to bank. Weekly payroll for employees which
includes set up of online payroll service Intuit online payroll.
Calculation and tabulation of payroll taxes.
w Responsible for Quarterly tax form preparation and filing, 941, CA DE
6, CA DE 9.
w Annual tax forms 940 Federal filing, 944 annual tax, and W-2 form for
employees. CA DE 7 for State of CA. Monthly calculation of formula for
employee payroll for Workers Compensation State Fund payment. Employee
and Contractor set up into online payroll service, Intuit.
w Preparation of 1099 forms to subs. Obtains permits from various
agencies for sewer mains, laterals and septic conversions.
w Maintain logs for bonds out to said agencies for various construction
projects. Knowledge of plans for sewer mains.
General office equipment, calculator, computer, fax and copy machine.
Contra Costa County, Martinez, CA
Lead Senior Medical Record Technician-Mental Health Division 7/2000-
6/2005
w Custodian of records for the Mental Health Division.
w Supervisor for Medical Record Department throughout the Mental Health
Division.
w Trained and coordinated the work of Medical Records Technicians and
other clerical staff.
w Responsible for all Subpoenas and Court Orders for the Mental Health
Division
w Coordinated with many program managers and staff to set up chart rooms
in Adult and Children's Mental Health Programs.
w Served on HIPAA committee, and the FORMS committee.
w Supervised and hired 3 MRTS. Central, East and West County.
w Analyzed medical records for chart content and documentation
requirements.
w Assigned diagnostic and procedural codes for billing and statistical
indices.
w Assisted physicians in the completion of disability, compensation
insurance and authorization forms.
w Assisted Registered Health Information Technologists in the
preparation of abstracts of medical records for use in the completion
of disease and surgical.
w Reviewed all non-authorized claims to determine eligibility for
benefits payment under Contra Costa Health Plan
w Reviewed, and processed pending disability claims.
w Reviewed and processed Medi-Cal revenue recovery reimbursement claims
from various providers for County covered patients.
w Ordered supplies for chart rooms in many various locations.
Medical Record Technician- CCRMC and Health Clinics 1990-2000
w Completes detailed analysis of medical records for completeness,
accuracy, and compliance with all applicable regulations
w Assigns diagnostic and procedural codes for billing and statistical
indices using the ICD-9-CM and CPT-4 coding classification system
w Reviews medical records for documentation on billing issues (patient
accounting)
w Assists physicians in the completion of disability, Worker's
Compensation and medical insurance forms
w Assists physicians with correspondence for legal and insurance
information
w Answers questions from health care providers and the general public
requesting information related to the processing of medical record
information
w Processes subpoenas and other legal requests and appeals relative to
the release of medical and billing information
w Assists in the training and orientation of new employees, and may
provide input to supervisor on clerical staff performance evaluations
w May process child health and disability prevention (CHDP) billing
forms
w Prepares birth certificates by gathering data and/or signatures from
patients, physicians and medical records and transmits information to
state and local registrar
w Assists in preparing and filing applications to amend a record by
affidavit, or assists patients in completing the application to amend
a record by affidavit
w May assist in monitoring the phenylketonuria (PKU) screening tests for
newborns and notifies the State Department of Health Services if the
PKU was not done
w May assist the liaison between the Health Services Department and the
State Health Department with the registration of vital statistics
documents
w Assisted physicians with completion of death certificates including,
contact with mortuaries, Coroner's Office, Social Service, and patient
families
w Planned, assigned and reviewed the work of clerical staff engaged in
medical records processing activities and serves as backup as needed
w Entered and screened data in various computer systems
w Transport patient medical records between job sites
w Provided and promoted excellent customer service for all internal and
external customers
w References: "Available upon mutual interest."
Previously employed with Contract Costa County as Clerk (12/1987-
10/1990).
CERTIFICATION
AAPC
CPC-H Certified - 01161639, 2/2013
EDUCATION
Liberty Union Adult School, Brentwood, CA
Certificate of Completion, 9/2010
Healds Business College, Walnut Creek, CA
Computer and Business Classes, 1/1986
Los Medanos College, Pittsburg, CA
Business and Computer Classes, 12/1985
FIDM - Fashion Institute of Design and Merchandising, San Francisco, CA
Merchandising 9/83
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