Ophelia Calixte

Delray Beach, FL *****

ad1zrf@r.postjobfree.com

+1-843-***-****

Medical Site Reviewer (1099)

March, 2012 – Currently

Medical reviewers work in hospitals, physician offices, nursing homes, and for independent auditing firms.

Review or audit medical records for completeness and accuracy by looking at various pieces of documentation. Incorrect or missing documentation can result in loss of hospital accreditation, a physician's license, or Medicare status.

Medical reviewers look at each individual medical record to check for missing documentation; they also check for physician's notes that show any evidence of patient neglect or abuse and verify that the correct member of staff has signed all paperwork.

When the reviewer finds a problem with the record, a citation is issued to the medical staff member. The member is given a deadline to fix the mistake.

A follow-up conducted by the reviewer is done to ensure the record is up to compliance.

Communicated effectively with clients and medical professionals

Scheduled clients serving four medical offices, taking into consideration client location, facility capabilities, insurance requirements, and type of exam

Followed up with doctors' offices to ensure proper exams are scheduled for clients

Consistently recognized as top scheduler to achieve company benchmarks

Performed administrative tasks as needed

Scheduling Home Healthcare – Evaluation RN, PT, RN, NA

CareCentrix, Carelon, Availality etc.

Remote Customer Service Representative

Diagnostic Professionals, Inc. - Fort Lauderdale, FL

August 2014 to 2016

Responsible include day-to-day operation of the managed care facility.

Assessment for Home Health Care

Tracking Case Management/RN's/Nursing Assistant

Scheduling home visits

Coordinate the actions of all departments and ensure the function

Development of operating objectives and budgets

Create an overall system for efficient delivery of medical services

Review financial reports, managed care contracts and major expenditures.

Establish and administer policies, and ensure they were uniformly understood.

Knowledgeable as to the essential for hospital administers to successfully manage patient care

Serve as liaison between medical staff, department heads and governing boards.

Supervise, and mentored staff, relating to the community and interfacing with boards.

Involve in recruiting, hiring, and training physicians, nurses, and assistant administrators.

Travel to conferences, satellite facilities

Instructor, Medical Billing and Coding, Robert Half Contract

Centura College, South Carolina, April, 2011 – January, 2012

Accurate and timely completion of patient record coding.

Performs coding activities to assure accurate completion of coding for all patient records; including reviewing for each charge submission for accuracy, adding appropriate modifiers, scrub claims, technology scrub, prepare for insurance, and close the clean batches.

Investigation and resolving coding related issues

Analyzes medical records for completeness of documentation with direct communication to providers for clarifications on any incomplete or conflicting documentation.

Keeps current on all coding related regulations, standards, guidelines, industry trends and Medicare announcements. Serves as a coding expert and resource for all payers.

Assists in providing coding compliance activities by conducting random audits on medical charts.

Educates physicians, clinicians, and other healthcare staff on changes to coding standards and regulations and advocates proper documentation practices.

Assistant Administrator, Health Services

NHP - Miami, FL

June 1992 to August 2011

Assist in the daily operation

Creation of business plan

Site planning

Clinical safety measurement and outcomes analysis

Preparation of a Medicare cost report

Creation and analysis of appointment access indicators

Third-party reimbursement and contracting analysis

Patient Relations - patient satisfaction analysis

Maintain individual provider files to include up to date information needed to complete the required governmental and commercial payer credentialing applications

Maintain internal provider grid to ensure all information is accurate and logins are available

Update each provider’s CAQH database file timely according to the schedule published by CMS

Apply for and renew annually all provider licenses; Professional, DEA, Controlled Substance

Complete credentialing applications to add providers to commercial payers, Medicare, and Medicaid

Complete re-credentialing applications for commercial payers

Credential new providers and re-credential current providers with hospitals at which they hold staff privileges

Work closely with the Revenue Cycle Director and billing staff to identify and resolve any denials or authorization issues related to provider credentialing

Maintain accurate provider profiles on CAQH, PECOS, NPPES, and CMS databases

Supervision of patient scheduling, registration, financial counseling, medical records, billing and collection, data entry and processing, and cash posting

Promoting excellent customer service

Develop, implement, and maintain office policies and procedures

Interview, hire and train a productive medical office team

MD, Office Manager

Dr. Lois Richardson - Washington, DC

June 1985 to March 1992

Congress of Christian Education

Nashville, TN Remotely (presently) Graduating Friday, July 21, 2023 Phase One

Skills

Medical Terminology, Coding, Word Excel, E-file, Credentialing, Workers’ Comp/Legal Assistant etc.

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