Medical Manager

John K. McCauley

**** ********* ****, ******, ** 27712

919-***-**** (H)

919-***-**** (W)

919-***-**** (C)

**************@*****.***

Summary: I am a highly skilled and experienced healthcare administrator

with over 20 years in the field. My experience includes every aspect of

the revenue cycle, from insurance verification to coding, charge capture,

billing and account follow up. This includes hands on experience as well

as supervisory/management in many of these areas. I will bring all this

experience plus an unparalleled work ethic that will prove to be an asset

to any company looking for the best they can get.

Core Competencies: Proficient in use of various practice management

coding and billing software systems, including MYSYS Vision, White Plume,

IDX, MDeverywhere, eBrowser, Netscape, Siemens SMS, Encoder Pro, as well as

Excel, Word, Powerpoint. I also have taken additional workshops, seminars

and training classes pertaining to healthcare, including Medicare,

Medicaid, BCBS billing/coding regulations, ICD-10 as well as accounting,

finance and managing multiple priorities, among others.

Professional Experience

Raleigh Orthopaedic Clinic, Garner, NC 2011 -

present

Manager, Central Billing Office

. Oversee, coordinate and direct the activities of the Central Billing

Office and other key aspects associated with the revenue cycle of the

practice, including the Medical Records Department for 5 outpatient

clinics, 2 physical therapy clinics, 2 athletic performance centers

and associated DME and Orthotics and Prosthetics business lines.

Direct and coordinate the hiring and activities of the staff. Serve

as the main point of contact for billing and insurance matters for all

services provided by the practice. Assist and serve as a resource in

the establishment and review of records for coding and compliance with

internal and external guidelines. Establish goals and benchmarks for

the performance of the billing and collections department. Review and

refine reports and reporting of key information related to the billing

and collection function. Provide periodic information and reports to

providers and management on billing and collection matters. Review

and participate in managed care negotiations. As required, represent

ROC and all departments in claims disputes with payers. Periodically

prepare reports related to month, quarter and year-end needs.

. Reduced A/R greater than 150 days from 21% as of 12/2010 to < 1% as of

10/2013.

. Increased A/R less than 90 days old to 97% as of 10/2013, from 71% as

of 12/2010.

. Reduced DRO from 50+ days to 31.

. Denial rate is now 7.67 %.

Duke University Health System, Durham, NC

1999 - 2011

Medical Coder, Coding Operations 2010 -

2011

. Coordinate/review the work of subordinate employees and assist with

the training and continuing education programs. Code medical records

utilizing ICD-9-CM and CPT-4 coding conventions. Review the medical

record to assure specificity of diagnoses, procedures and

appropriate/optimal reimbursement for hospital and/or professional

charges. Abstract information from medical records following

established methods and procedures.

. Consult with and educate physicians on coding practices and

conventions in order to provide detailed coding information.

Communicate with nursing and ancillary services personnel for needed

documentation for accurate coding.

(On Medical Leave from 1/2008 - 6/2010)

Supervisor, Coding and Charge Capture 2005-

2008

. Team leader for coding/billing section of conversion to

MDeverywhere, resulting in reduction of missed charges with

subsequent increase in revenue.

. Wrote policies and procedures resulting in coding quality audits

with monthly accuracy ratings of 97-100% as well as

procedural/operational audits of 100%.

. Updated billing system edits, reducing a number of coding/billing

denials by 20%.

Manage all coding and billing processes for professional services at 3

hospital/surgery centers, including auditing of medical records and

obtaining prior authorizations. This includes writing policy &

procedures, physician education, hiring staff. The services

responsible for include the Hospitalists, ICU, other inpatient

services, OB-Gyn, Ophthalmology, Interventional Radiology, surgery,

palliative care, Special Cardiology Surgery, Allergy & Airway and

Cardiac Cath. Responsible for review and analysis of monthly financial

reports for various services: research coding/billing deficiencies and

implement corrective actions. Audit coding/documentation of

physician/coding staff. Perform ICD/CPT surgical coding. Interact

daily with senior management, physician enrollment department,

physicians, and payors. Maintain and verify records of filing

procedures/requirements for various insurance carriers, i.e.,

Medicare, Medicaid, BCBS, and Workers Compensation. Supervision of

staff up to 7.

Reimbursement Specialist 2004-

2005

. Leader for special projects to decrease backlogs in coding and

billing. Cleaned up $3,000,000 in charges that were held for coding

edits/errors for the Ophthalmology Department, coding ED consults for

Orthopedics, Otolaryngology and Plastics Divisions.

. Served as the surgical coder for Ophthalmology and the Ambulatory

Surgery Center at Duke.

Practice Specialist-ENT/Plastics/Oral Surgery/Orthopaedics

2002-2004

. Team leader on project to implement MDeverywhere for Emergency

Department consults resulting in over $1million in annual revenue.

. Member of co-surgery billing improvement team which resulted in proper

coding and documentation leading to a 25% increase in revenue for co-

surgery cases.

. Identified $92,000 account denied for no authorization. We had prior

authorization but procedure occurred outside the authorization dates.

Contacted carrier, they agreed to extend the authorization period

which resulted in a $65,000 payment.

Identified revenue enhancement opportunities and implement solutions toward

maximizing revenue. Provide essential feedback to physicians/providers

regarding coding and denials. Work coding denials file, making appropriate

corrections and re-file claims. Work coding/pre-billing edit file, making

necessary corrections and/or adjustments for filing claims. Interact with

physicians, clinical personnel, coders, patients and insurance carriers on

a daily basis. Train other Practice Specialists in sorting and working

edits/coding denials files. Chairperson of several management projects: ED

Consult Charge Capture, Co-surgery Billing Process Improvements. Member of

Perioperative Improvement Team. Practice Specialist lead in Coding Denial

Revenue Enhancement Team.

Reimbursement Analyst II - Professional Billing

2001-2002

. Initiated coding/billing corrections or adjustments on $3 million in

denied charges for Neurology Department resulting in collection of $1

million+ in reimbursement.

Resolved pre-billing edits. Decrease/eliminate coding related denials based

on review of charges prior to claim submission. Ensure proper/ timely

filing of charges by reviewing documentation related to edited charges.

Remain current on Medicare Teaching Physicians Guidelines, CPT/ICD coding,

as well as other applicable guidelines/regulations. Provide feedback to

appropriate personnel on coding and documentation processes. Provided

enhancement of processes through research and analysis of guidelines and

systems, including coding recommendations, addition/elimination of edits,

identify training opportunities. Work on special coding reimbursement

projects as requested.

Reimbursement Analyst II - Reimbursement Department

1999-2001

. Resolved coding/billing edits and denials; ensure appropriate

processing of charges by compiling and reviewing documentation related

to denied/edited charges. Remain up to date on Medicare Teaching

Physician Guidelines, E/M coding guidelines, and other applicable

guidelines. Provide feedback to the appropriate personnel in coding

and documentation process. Monitor charges in coding/billing work

files. Decrease/eliminate coding related denials based on review

findings. Provide enhancement of systems and processes through

research and analysis of appropriate guidelines: coding

recommendations, add/eliminate edits, identify training opportunities

and provide feedback to appropriate persons. Develop written policies

and procedures with other relevant personnel as necessary.

Durham Regional Hospital, Durham, NC 1999

Patient Accounting Manager

. Set up team concept. Each team responsible for specified insurance

carriers. This allowed for better understanding/knowledge of carrier

requirements leading to increased reimbursement and lowering DRO's by

20%.

. Performs supervisory work in the Patient Accounting area to ensure all

operational activities are performed efficiently and accurately by the

staff in a timely manner. Responsible for establishing and maintaining

overall policy and procedures and coordinating operations with other

hospital units and medical staff. Interview, select, hire, train,

counsel and discipline employees. Responsible for ensuring collection

procedures are followed, insurance claims are filed and associated

records are maintained. Work closely with all areas of Patient

Financial Services, such as Billing, Cashiering and Follow-up

Collections, to ensure patient accounts are processed timely and

accurately. Review department performance in relation to established

goals. Implement changes to effect continual improvement in services

provided, and assure compliance with regulatory and legal

requirements. Supervised staff of 12.

Previous relevant work history

Reimbursement Analyst II - Reimbursement Department, 1998-1999 - Duke

University Medical Center

Coding Specialist 1997-1998 - UNC Physicians and Associates

Healthcare Business Resources, Durham, NC- 1990-1997 Senior Operations

Analyst. Medical billing company for ED's in 26 states.

NaRe (North American Reassurance Company), New York, NY-1985-1989- Senior

Claims Analyst

New York Life Insurance Company, New York, NY 1980-1985- Senior

Compensation Analyst

Education

B.A., Sociology, Cortland State University

Accreditations and Professional Associations

Certified Professional Coder (CPC)

National Legislative Chair - AOA 9/04 - 9/07

Member Communications Committee AOA 9/04 - 12/07

AOA Member 12/02 - 9/08

MGMA 2012 - present

Triangle Managers Association 2012 - present

Contact this candidate