Ms. Harvey L. Johnson, CPC, CPMA, CEHRS, CBCS, CMA

P O Box 24891

Tampa, FL 33623

Phone: 813-***-****

adipsl@r.postjobfree.com

OBJECTIVE:

To acquire a challenging position which will utilize my broad experience, high level of expertise in the development and attainment of corporate goals, in order to achieve excellence in service.

EXPERTISE AND ACHIEVEMENTS:

Over 25 years of experience in the field of Claims Processing, Claims Review, Customer Service, Hospital and Physician Auditing, Quality Assurance, Medical Collections, Medical Billing and Various Specialties of Medical Coding, with 15 years at Managerial/Supervisory Level.

PROFESSIONAL EXPERIENCE

VeriMED IPA

Jan 2019 – Present

Lead MRA/HEDIS Analyst-Provider Educator

•Responsible for working with providers in the areas of Hierarchical Condition Category (HCC) Coding accuracy and Quality/HEDIS for complaint, accurate and complete documentation, and submission of claims and other reporting..

•Reviews ambulatory and inpatient medical charts in EHR for prospective and retrospective coding of chronic conditions which map to HCCs.

•Facilitate and/or performs audit of the provider's medical chart to ensure appropriate documentation exists to support the diagnoses submitted appropriately.

•Assists providers in the areas of Hierarchical Condition Category (HCC) Coding accuracy and Quality/HEDIS for complaint, accurate and complete documentation, and submission of claims and other reporting.

•Ensures accuracy of ambulatory and inpatient medical charts in EHR for prospective and retrospective coding of chronic conditions which map to HCCs, educate providers on Risk Adjustment Coding and Documentation Guidelines and necessary quality of care measures to improve both HCC and care gap closure rates.

•Assesses provider workflow to analyze Provider office processes and recommend improvements.

•Educate providers and staff on coding regulations and changes as it relates to Quality and Risk Adjustment to ensure compliance with state and federal regulations. Responsible for HEDIS data collection, measures, analysis, and reporting.

•Provide extended education to providers, and/or staff on Risk Adjustment Coding and Documentation Guidelines and necessary quality of care measures to improve both HCC, MRA, HEDIS and care GAP closure scores

•Develop strategies to improve HEDIS data collection and outcome improvement.

•Monitor adverse HEDIS trends and recommend modifications and/or corrective action.

Avalon Health Care Solutions

Jan 2018 – Jan 2019

Senior Medical Coding Analyst

•Accurately and comprehensively identify appropriate ICD, CPT, and/or HCPCS codes that correspond to Medical Ppolicies.

•Communicate findings and/or issues with members of the Quality Improvement and Clinical Operations Departments to help ensure accurate Medical Policies deliver compliant objectives to improve the efficiency of clinical lab testing.

•Translate lab medical policy narrative into appropriate ICD, CPT, and/or HCPCS codes to facilitate prior authorization activity and/or appropriate system adjudication.

•Provide guidance to Utilization Management staff regarding policies and codes associated with prior authorization.

•Liaise with various Operations team members to ensure that business rules mirror policy intent.

•Contribute content to facilitate communication with and education of the provider network regarding lab medical policy.

•Identify lab claims system coding issues and assist in the formulation of system efficiency recommendations to ensure exceptions reduction through accurate coding.

•Participate in the analysis of lab claim coding trends. Identify potential root causes of trends, and recommend changes in methods, procedures, and policies in order to improve quality and consistency with industry standard coding guidelines.

Addison Group–HIM

Jan 2018 – Jan 2019

Remote Multi Specialty Physician/Facility Auditor (Contract)

•Assigned to Vanderbilt University Hospital, a 978 bed, Level I Trauma, Teaching Facility

•Reviewed Emergency Room physician narratives, assigned appropriate ICD-10CM, ICD-10PCS, CPT, and/or HCPCS codes as required, for future billing purposes, from patient’s triage to admission to ICU, CCU, Surgical Care, discharge, or appropriate disposition. Coded all major trauma charts to include: Gun-shot wounds, Motor Vehicle Accidents, Occupational Accidents, in addition to various other accidents.

•Charts included, multiple fractures, minor and major surgical procedures, IV medications and/or infusions.

•Researched necessary information for adherence within regulatory compliance with CCI, and CMS guidelines.

•Reviewed, analyzed, and interpreted clinical documentation applying, ICD-10CM, ICD-10PCS, CPT, HCPCS, APC codes, DRG’s, modifiers, Revenue Codes and participating physician codes with an understanding of how each is used and the impact the accuracy has on mortality rates, clinical quality, reimbursement, internal score cards and key quality indicators.

•Provided comments on the overall encounter documentation for physicians and provided a report on procedures not documented adequately for code assignment.

Equity Staffing Group (United Health Care-Contract) FL

July 2017 – Jan 2018

Remote Clinical Documentation Review Analyst

•Reviewed documentation for accuracy of CPT, ICD-10 and HCPCS.Codes.

•Documented fact based decisions in Case Management System.

•Examined, assessed, and documented business operations and procedures to ensure data integrity, data security and process optimization.

•Investigate, recover, and resolve all types of claims as well as recovery and resolution for health plans, commercial customers, and government entities.

•Identified potential Fraud, Waste and Abuse, followed by due diligence.

•Investigated and pursued recoveries and payables on subrogation claims and file management

•Ensured adherence to state and federal compliance policies, reimbursement policies, and contract compliance.

•Use pertinent data and facts to identify and solve a range of problems within area of expertise.

•Ensured all Medical documentation was entirely in alignment with claims reimbursement as related to applicable coding, and/or billing practices

Independent Medical Consultant Tampa, FL

Jun 2011 – Present

Remote/Onsite Coder/Auditor/Educator (PRN)

•Consults and assesses business-related issues for medical facilities and healthcare providers so they can prioritize providing care. Gather and analyze data, finalize conclusions and present findings in the form of recommendations to clients.

•Offer salary, staffing, budgeting and advertising suggestions.

•Advise standardizing the delivery of patient care, in accordance with Compliance Standards.

•Assist physicians and/or or healthcare facilities with a range of regulatory issues, such as complying with insurance company guidelines and procedures, operating plans, keeping patient information confidential as well as protected, (HIPPA focsed), and the proper disposal of hazardous waste, if deemed necessary.

•Suggest ad identify options that emphasis ways client can lower exposure to malpractice lawsuits or address such lawsuits when they come up, or act as an expert witness on the behalf of the client.

•Interview potential customers and/or clients in order to gather pertinent information relative to resolution of issues. Interaction with patients, to evaluate how well the physician is performing in the treatment of his/her patients. based on patients the responses regarding to quality of care, make necessary recommendations of ways the client can increase and or improve patient satisfaction.

•Develops project plans and strategies in line with a client’s business needs.

•Collaborate with healthcare or medical company start-ups, to establish the specifics of effectively starting a business.

•Identify and resolve potential problems, such as in workflow or company processes and also offer advice for optimizing hospital, health center or medical-center facility performance.

•Review documentation for accuracy of CPT codes

•Document fact based decisions in case management system

•Examine, assess, and document business operations and procedures to ensure data integrity, data security and process optimization.

•Investigate, recover, and resolve all types of claims as well as recovery and resolution for health plans, commercial customers, and government entities

• Investigate and pursue recoveries and payables on subrogation claims and file management

• Ensure adherence to state and federal compliance policies, reimbursement policies, and contract compliance

•Use pertinent data and facts to identify and solve a range of problems within area of expertise

AMERICAN HEALTHCARE TECHNOLOGIES Tampa, FL

Aug 2016 – July 2017

Director of Coding Operations

•Provides strategic guidance and direction for the provision of coding services by planning and executing short and long term strategic actions throughout the region supporting the Medicare, Advantage Care 65, and various other Government Program's mission, goals, policies and procedures, relative to HEDIS, and Risk Adjustment.

•Created and managed a strong culture that understand and support the CMS Program's vision and philosophy.

•Active leader in the Region's Revenue Cycle processes to meet CMS’s defined goals and objectives.

•Maintained comprehensive knowledge of contemporary coding practices and emerging technology (i.e. Clinical Information Systems; EHR) to ensure coding services and infrastructure are progressive and effective.

•Worked closely with other business support departments, and entities to coordinate and oversee efforts, share best practices and promote consistency in processes, with regards to HCC, MRA, and HEDIS coding and compliance procedures. .

•Provided vision, leadership, development, operational compliance and fiscal management for the regional coding services including professional and hospital coding.

•Developed, defined, and executed project plans.

•Accountable for creating a culture of compliance, ethics, integrity and performance in alignment with CMS standards.

•Developed communication strategies and processes for communicating to coding team members as well as senior leadership.

•Communicated needs to include success metrics, project updates, policy changes, system enhancements, etc.

•Established, managed and evaluated coding and auditing quality measures.

•Responsible for the development of quality management program.

•Focused on achievement of compliance with state and federal laws, regulatory agencies, administrative and medical/legal risk assessments and accepted professional practice standards.

•Evaluated and planned for advanced technology to enhance the quality of coding.

•Developed vision and strategy for completeness and accuracy of documentation for accurate code capture of HCC diagnoses, HEDIS Measures and Medicare Risk Adjustment procedures and services.

WELLCARE HEALTH PLANS, INC. Tampa, FL

July 2013 – Aug 2016

SIU Medical Coding Auditor

•Responsible for conducting comprehensive review of medical records and documents supporting claims for medical and behavioral health care services, with an emphasis on Fraud, Waste and Abuse..

•Provides investigative support to the Special Investigations Unit (SIU) related to coding and billing issues and identifies potential overpayments and suspected health care fraud and abuse.

•Reviews medical and behavioral health care medical records, and independently codes, abstracts and analyzes inpatient and outpatient medical records using most current International Classification of Diseases (ICD-9), Current Procedural Terminology (CPT), Health Care Common Procedure Coding System (HCPCS), Universal Billing (UB) and other codes, according to federal and state statutory, regulatory and contractual requirements, AMA guidelines, and generally accepted coding practices.

•Verify and validate authorization of services, written clinical documentation of services received through health services and behavioral health utilization management departments, and information contained in the health care claim systems against claims, medical records and other documentation submitted by the provider, and identifies coding errors, inconsistencies, anomalies, abnormal billing patterns, and other indicators (e.g., services not rendered, up-coding, un-bundling, etc.) of suspected fraud and abuse.

•Coordinates and initiated individual work activities with SIU investigators, develops and presents findings and recommendations regarding the appropriateness of diagnosis and procedure codes submitted on provider service claims, and supports overpayment recovery during discussions with medical and behavioral health care providers.

•Educates medical and behavioral health providers and administrative support staff at all levels on federal and state statutory, regulatory and contractual requirements, appropriate coding according to AMA guidelines, acceptable practice standards, and procedures for preventing and reporting potential fraud and abuse.

•Coordinates coding and payment issues with other areas and departments as required.

•Responsible for presenting educational seminars on fraud and abuse awareness, detection and reporting to areas and departments as required.

•Presents findings and provide testimony in legal proceedings as required.

TRANSATLANTIC HEALTHCARE, LLC Tampa, FL

Apr 2012 – Nov 2013

Medicare Risk Adjustment HCC Coding Consultant/Auditor

•Review health care medical records, and independently codes, abstracts and analyzes inpatient and outpatient medical records using most current ICD-9, CPT, HCPCS, Universal Billing (UB) and other codes, according to federal and state statutory, regulatory and contractual requirements, AMA guidelines, and generally accepted coding practices.

•Verifies and validates authorization of services, written clinical documentation of services received through health services, health utilization management departments, and information contained in the health care claim systems against claims, medical records and other documentation submitted by the provider, and identifies coding errors, inconsistencies, anomalies, abnormal billing patterns, and other indicators, as related to services not rendered, up-coding, un-bundling.

•Completes HEDIS chart reviews and audits.

•Coordinates individual work activities with management as well as healthcare services provider.

•Develops and presents findings and recommendations regarding the appropriateness of diagnosis and procedure codes submitted on provider service claims, and supports overpayment recovery during discussions with health care providers.

•Educates health providers and administrative support staff at all levels on federal and state statutory, regulatory and contractual requirements, appropriate coding according to AMA guidelines, acceptable practice standards, and procedures for preventing and reporting potential fraud and abuse.

CONTRACT CODING COMPANY Tampa, FL

July – 2015 – Jan 2016

Remote Audit Specialist (Contract) PRN

•Established policies and procedures.

•Conducted coding quality review audits in compliance with the coding compliance plan and established standards, specified by particular sites, as well as within compliance with CMS, and NCCI standards.

•Supported the review activities that drive hospital revenue including revenue cycle initiatives, internal audit plan, reimbursement audits (RACs, MPRO) and data quality.

•Key support for the coding areas and staff. Assisted in personalized, remedial coding training as deemed necessary.

•Applied ICD-9 codes, ICD-10CM codes, ICD-10-PCS codes, DRG codes, present on admission codes, patient status codes, and participating physician codes with an understanding go how each is used and the impact the accuracy of the data has on mortality rates, clinical quality, reimbursement, internal score cards and key quality indicators.

•Tracked quality performance standards for assigned team of coding specialist.

PYRAMID HEALTHCARE SOLUTIONS/ANTHELIO HEALTHCARE Clearwater, FL 2011 – 2016

Remote Emergency Department Coder III(Pyramid)—Integrity Revenue Auditor(PRN)

•Reviewed Emergency Room physician narratives, assigned appropriate ICD-9, CPT, and/or HCPCS codes as required, for future billing purposes, from patient’s triage to admission to ICU, CCU, Surgical Care, discharge, or appropriate disposition. Coded all major trauma charts to include: Gun-shot wounds, Motor Vehicle Accidents, Occupational Accidents, in addition to various other accidents.

•Charts included, multiple fractures, minor and major surgical procedures, IV medications and/or infusions.

•Researched necessary information for adherence within regulatory compliance with CCI, and CMS guidelines.

•Reviewed, analyzed, and interpreted clinical documentation applying ICD-9 codes, ICD-10CM codes, CPT codes, APC codes, DRG’s, modifiers, Revenue Codes and participating physician codes with an understanding of how each is used and the impact the accuracy has on mortality rates, clinical quality, reimbursement, internal score cards and key quality indicators.

•Performed onsite audits as deemed necessary.

•Provided comments on the overall encounter documentation for physicians and provided a report on procedures not documented adequately for code assignment.

SANFORD BROWN INSTITUTE OF TECHNOLOGY, Tampa, FL

2011 - 2012

Lead Medical Coding and Billing Instructor

•Instructed assigned courses in accordance with Medical Billing and Coding guidelines, to include proficiency in ICD-9, CPT, HCPCS Coding, as well as Billing Techniques.

•Adequately prepare all course materials and lessons.

•Provide students with clear course expectations, evaluations and timelines through carefully written topical outlines and approved, standardized syllabus.

•Provide Interesting and relevant assignments for students that demonstrate learning outcomes in a real-life billing and/or coding setting.

•Suitably challenge, engage, serve and communicate with students to encourage their participation and learning while maintaining mutual value and respect.

•Complete grade books, final grade sheets, learning assessments and final exam assessments on a timely basis.

•Identify and refer at-risk students to specific academic support services. Ensure course and program learning outcomes are delivered as defined by the syllabus.

ELLIS, GED, BODDEN, PA, Clearwater, FL 2010 – 2011

Subrogation Representative (Contract Assignment)

•Investigated coverage, liability and damages for heavy bodily injury, and worker’s compensation claims, property damage, and other various legal actions brought against our insured's as well as various Medical Clients, (ie Chiropractors, and/or Physical Therapists).

•Generated demand letters on the behalf of clients, to various PIP insurance carriers, or medical insurance companies, in accordance with State Statues.

•Managed 150 or more litigation files to final resolution through focused negotiations and/or by assisting defense counsel and/or team in developing appropriate action plans and strategies for defense up to and including trial.

•Maintained loss and expense reserves according to case facts as they are developed and track key litigation information through the suit register.

LYNX MEDICAL SYSTEMS, INC. Tampa, FL

2003 – 2010

Lead Remote Medical Coding Specialist

•Reviewed Emergency Room physician narratives, assigned appropriate ICD-9, CPT, and/or HCPCS codes as required, for future billing purposes, from patient’s triage to admission to ICU, CCU, Surgical Care discharge, or appropriate disposition.

•Coded all major trauma charts to include: Gunshot wounds, Motor Vehicle Accidents, Occupational Accidents, in addition to various other accidents.

•Charts included, multiple fractures, minor and major surgical procedures, IV medications and/or infusions.

•Researched necessary information for adherence within regulatory compliance with CCI, and CMS guidelines.

•Reviewed, analyzed, applied, and interpreted clinical documentation applying ICD-9CM(Vol 1&2) Codes, ICD-9 Procedure Codes (Volume 3) codes, CPT codes, HCPCS Codes, APC codes, DRG’s, appropriate Modifiers, and Revenue Codes. Performed onsite audits as deemed necessary.

•Provided comments on the overall encounter documentation for physicians and provided a report on procedures not documented adequately for code assignment.

•Generated charge logs, evaluated practice management and administrative data, and reported codes to the billing system.

GRACE BILLING SERVICES Daytona Beach, FL

Remote Claims Processor/Reviewer (Part-Time)

•Processed government (Medicare and Medicaid) and commercial medical insurance claims, both facility (UB92) and provider (HCFA 1500), for Chiropractor, and Physical Therapist, related to various accidents, and Third Party Liability.

•Provided expertise or general claims support to appropriate areas in reviewing, researching, investigating, negotiating, processing and adjustments of related claims.

•Reviewed, prepared and resolved EOB denials, and/or appeals, as well as patient account inquiries and collections.

•Conducted data entry and re-work; for follow-up with appointed carriers, involved parties, or representation.

•Analyzed, and identified trends and provided reports as deemed necessary to resolve relative issues. Reviewed DRG’s, APC’s, RVU’s, to ensure accuracy.

CONCORDE CAREER INSTITUTE Tampa, FL

2000 - 200 5

Insurance Coding-Billing Specialist Instructor (Part-time)

•Trained students to become proficient in Medical Insurance Billing, ICD-9, CPT, HCPCS, and

•Dental Coding. Performed bi-monthly student progress evaluations.

•Managed instructional classroom setting with up to 25 adult students.

•Prepared students to take the Certified Professional Coder Examination.

•Generated monthly and end of term grades, and reports.

•Tutored students that had fallen below guideline standard, or with language barriers.

•Assisted in Medical Assistant labs when required.

•Various others duties as assigned.

•Ensure course and program learning outcomes are delivered as defined by the syllabus.

BRANDON RADIOLOGY/TEAM HEALTH Tampa, FL

2002 -2003

Senior Medical Coder

•Reviewed inpatient and outpatient radiology reports, selected appropriate ICD-9, CPT, and/or

•HCPCS code required for finalization of billing.

•Coded Interventional Radiology charts, as well as special fluoroscopy assisted procedures, to include Heart Catheterizations, Ablations, Stent placements and/or removals, and other Cardio-related procedures.

•Reviewed Medicare, Medicaid, and various Third-Party Administrator denials for reprocessing.

•Tracked on-line UPIN information, from various states for provider participation, and eligibility.

•Attended numerous seminars for Continuing Education Units.

SUNCOAST INSTITUTE OF TECHNOLOGY Tampa, FL

2001 -2002

Medical Assistant-Medical Coding and Billing Instructor

•Trained students in both technical (Patient care, Vitals, Phlebotomy, and Injections) and administrative (Professional Development, Medical Terminology, Anatomy & Physiology, and Insurance Billing) aspects of becoming a Medical Assistant.

•Counseled and tutored students that fell below the required GPA.

•Managed classroom setting for up to 35 adults, and maintained appropriate records for each student.

•Conducted monthly evaluations, and feedback session as deemed necessary.

REHABILICARE, INC. Tampa, FL

1999 - 2000

Medical Collections Supervisor

•Supervised and coordinated activities of employees engaged in the process of individual, and insurance company collections. Analyzed aging credit, and revenue reports monthly as well as other information received.

•Monitored credit/debit activity for bad debit reserve projections.

•Resolved escalated issues requiring managerial decision. Hired additional staff.

•Initiated any corrective action plans, deemed necessary.

•Processed claims for payment in accordance to written policies and procedures. Facilitated Procedural and Diagnosis Code Training Classes.

SMITHKLINE BEECHUM CLINICAL LAB Tampa, FL

Billing Supervisor/Interim Manager

•Managed medical insurance billing, and data entry department. Tracked Medicare, Medicaid, and private insurance changes, as well as contract statuses.

•Monitored claims processing, and follow-up progress.

•Monitored managed care contracts for accuracy.

•Reviewed insurance EOB denials.

•Delegated appropriate actions for resolution..

•Evaluated employee progress and additional training requirements.

OXFORD HEALTH PLANS Tampa, FL

Operations Supervisor

•Coached, counseled and evaluated team of Customer Service Representatives, in a call center environment.

•Set objectives, consistently measured and analyzed individual performance to meet specific standards.

•Reprocessed denied claims.

•Ensured accurate file compilation for proper processing of claims and contracted payments.

•Handled escalated and/or irate issues, requiring managerial decision.

•Claims Operative Report Coding Liaison. Detailed coding documentation of surgical procedures.

CLEARWATER CLINICAL LABS, INC. Clearwater, FL

Billing Specialist Manager

•Managed daily accounts receivable transactions.

•Recorded and tracked monthly incoming revenues for each insurance carrier.

•Negotiated HMO, PPO, and other insurance contracts for participation.

•Monitored and communicated clearing house changes, for the effective transmission of electronic claim submittals.

•Maintained accurate claims and investigative reports, record keeping and the handling of all administrative responsibilities associated with the processing and payment of claims.

•Remained current on claim settlement process, processes and procedures.

•Ensured strict adherence of all company policies and practices, state and government regulations and/or statues.

•Facilitated informational presentations.

•Responsible for conducting Continuing Education Sessions.

BLUE CROSS BLUE SHIELD OF FLORIDA, INC. Jacksonville and Tampa, FL 1984 to 1997

Senior Membership and Billing Representative

Quality Assurance Supervisor

Senior Quality Assurance Analyst

Senior Case Management Analyst

Claims Specialist Team Leader

Claims Processor

Coordination of Benefits Analyst/Worker's Compensation Analyst/PIP Analyst

Medicare Secondary Payer Analyst/Subrogation Analyst

DME Prescription Reviewer/DME Medical Coding Review Specialist/DME Review and Reopen Analyst

Senior Customer Service Representative Medicare A & B

Medi-Gap Claims Specialist

Medicare Part B Correspondence Analyst

EDUCATION

Christian Family Church Bible Institue

Currently pursuing Bachelor’s Theology 2018

Member of NAMAS (National Alliance of Medical Auditing Services)

American Academy of Professional Coders

Certified Professional Coder

Certified Professional Medical Auditor

Tampa AAPC Chapter

New Member Development Officer 2013

Vice-President 2014

Officer of Education 2015

National Health Career Association

Certified Billing Coding Specialist/Certified

Certified Electronic Health Records Specialist

Jones College Jacksonville, FL

Certification Medical Assistant

WellCare Health Plans, Inc.

Certification of Compliance

Englewood Senior High School Jacksonville, FL

Diploma General Academics

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