Dayana Soto Dotres

**** ** *** ***

Miami, FL ***83

ad0hy2@r.postjobfree.com

305-***-****

WORK EXPERIENCE:

Second Wave Delivery Systems. Las Vegas, NV. Remote Position Clinical Risk Adjustment Coder March 2022— October 2023

• Review and analyze medical records, including clinical documentation, lab results, hospital documentation, office and consultant visit and treatment plans, to identify and document all relevant diagnoses for risk adjustment purposes based on CMS HCC categories.

• Review and analyze medical records, including clinical documentation, lab results, hospital documentation, office and consultant visit and treatment plans and findings HCC categories opportunities and create CDI in the EMR to support the Primary Care Providers

• Accurately code diagnoses using ICD-10-CM and other coding systems as applicable, ensuring Adherence to official coding guidelines.

• Formulates physician queries for validation of pathological/clinical findings, Request clinical validation queries for Clinical Documentation integrity (CDI) review and follow-up. Seeks clarification from providers or other designated resources to ensure accurate and complete coding.

• identify missed, dropped or suspect HCC opportunities, and assigns appropriate coding disposition. Utilizes mining from data captured through historical risk adjustment coding reports. IMC Health/ CareMax Miami, FL

Medical Billing and Coding July 2021—February 2022

• Responsible for the evaluation of medical documentation for proper assignment of ICD10- CM/CPT-4 codes and the preparation of claims.

• Seeks clinical documentation and makes coding recommendations to physicians based on their overall medical observation and documentation of medical records.

• Ensures medical records for accuracy and completion through pre audit and post audit processes to adequately code for all services to achieve reimbursement in accordance with correct coding guidelines.

• Provides PCP MRA/HEDIS coding support, education, training and medical documentation guidelines.

• Monitor coding changes to ensure most current information is available.

• Assists with chart reviews/audits performed by health plans.

• Looks for new problem areas, trends, etc.

• Works HCC/HEDIS Care Gap Reports.

• Maintain up to date coding innovations that can improve their workflow.

• Maintenance, reconciliation, and completion of PCP coding recommendations-Level 1 claims that have been corrected by physician.

Conviva Care Solutions Miami, FL

Medical Coder Specialist Nov 2020 – July 2021.

• Ensured compliance with established ICD-10 coding guidelines as well as CMS regulations.

• Review, analyze and code diagnostic information in patient’s medical records to ensure that codes assigned meet medical necessity requirements by Medicare and CMS regulations

• Apply and follow HCC guidelines for Medicare following the Risk adjustment process to ensure all active diagnosis supported by acceptable medical records documentation are coded correctly according to guidelines.

• Responsible for encounters submission for each member for every date of service; corrected encounters, as necessary.

• Accurately and timely bill claim for providers to ensure proper reimbursement. Assist Management in assigned tasks and projects, as necessary.

• Help clinicians improve their coding and documentation for MRA. Care Resource Community Health Center Miami, FL

Medical Coder Specialist at Medical Care Service Dept. July 2019 – Nov 2020

• Assigns accurate medical codes diagnoses based on the most updated set of ICD-10 guidelines.

• Retrospective review to assist healthcare providers in identifying and resolving issues related to incomplete or missing clinical documentation increase

• Assigns accurate procedure and evaluation and management services.

• Assigns accurate HEDIS when apply.

• Reviews all clinical progress notes. Obtain missing information from Providers and clinical staff members, and report them to the supervisor immediately and prior to processing the claim.

• Enter all necessary modifiers accurately.

• Post pending Medical and Behavioral Health charge in the EHR.

• Reviews the unresolved encounters report once every two weeks.

• Identify and resolving issues or errors, such as incomplete or missing records and documentation.

• Educates and advises providers and ancillary staff on proper coded selection, procedures and requirements.

• Help clinicians improve their coding and documentation for MRA.

• Pre audit and audit

• Support the billing team in verifying and correcting coding issues per insurances requests or claim denials.

Conviva /MCCI Group Miami, FL

Professional Coder at Billing Department July 2012 – July 2019.

• Ensure receipt of all progress notes, logs, walk-in notes, etc. at the end of the day.

• General coding for both Adult (geriatric) and children (pediatric) practices.

• Identify, compile and code patient data, using ICD-10-CM and CPT and other standard classification coding systems.

• Ensure progress notes are coded accurately and to the maximum level of specificity following established coding guidelines.

• Enter data. such as history and extent of disease, diagnostic procedures and treatment into computer database.

• Works with physicians for coding accuracy.

• Maintain diagnostic codes and informing appropriate medical staff. Maintain up to date on new coding regulations; Ability to understand, interpret and convey technical information. Charges Entry at Billing Department May 2012 - July 2012

• Receive and Review, Daily log, Daily Copay list, Daily Appointment list, Encounters Details and insurance verification from different medical centers.

• Enter diagnostic ICD-9 and CPT into the billing system.

• Carefully correct any mistakes, approve if it was the right course of action and enter into the billing system.

• Apply the copay to the patient into the billing system.

• Transmit the claims to the corresponding insurance companies.

• Attend incoming calls from the patients, review statements and charge the copay and statement balance as needed

Skills:

Microsoft Office, Word, Excel, PowerPoint. Experienced in system such as Intergy, Cerner, MDVita, Datalink, Nextgen. and ECW.

Languages: English, Spanish and Russian,

EDUCATION:

Excelsior Institute Certified Professional Coder (CPC), Miami FL 2012 Certified Risk Adjustment Coder, (CRC) Miami FL 2018 Certified Professional Medical Auditor (CPMA).Miami FL 2021 Documentation Improvement Expert Outpatient (CDEO) Miami.FL 2021 Kharkov Institute of Urban Engineers Kharkov, Ukraine Bachelors' Degree in Economy Sept 1989 - July 1993

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