Management
Resume:
Kristen Knox
Apollo Beach, FL 33572
adjmn7@r.postjobfree.com
Professional Experience:
Centene Corporation/WellCare Health Plans Tampa, FL
Clinical Policy Coding Analyst 2018-Present
Directs the initial review of coding in Clinical Coverage Guidelines (CCGs) to support the Medical Management Team byreviewing and updating evidence based clinical policy (and related coding rules and regulations) to support medical necessity reviews for authorization requests. Leads revisions to Claims Edit Guidelines (CEGs) as well as development of new CEGs.
Includes in depth research of State and Federal Regulations, coding industry guidelines, and other related WellCare policies.
Conducts research involving consistent evidence-based criteria and authorization rules in support of clinical decision making.
Oversees hand-off of all CCGs and CEGs to the Coding Integrity team to ensure final review of coding is completed and ensuring that necessary systems have the appropriate edits implemented.
Supports projects delegated to the Chief Medical Director of Medical Management (e.g., liaising with claims edit vendors,
Medical Expense Initiatives [MEI], strategic initiatives, Medicaid admits, authorization rules). Also includes cross-functional work and new market implementation (including vendor implementation).
Ability to meet productivity and accuracy standards and defend coding decisions to both internal and external audits.
Evaluates claims coding rule change request from clinical, financial, and claims operations perspectives. Includes providing
regulatory and coding research for items related to Medical Expense Initiatives (MEIs), as well as changes stemming from contractual requirements, implementation activities, etc.
Provides subject matter expertise on coding, including collaboration with markets and departments to support operations, product development, implementation, health outcomes, growth initiatives, and other business objectives.
Includes projects related to Medicare pre-service turnaround time and appeals as well as ensuring efficiency of the Medical
Management process inclusive of standardization in the authorization processes throughout the enterprise and any acquisitions.
Follows and has a complete understanding CMS risk adjustment guidelines and understands the impact of ICD codes on the CMS HCC risk adjustment model.
Coordinate and review activities to meet contractual, regulatory and, internal department standards
Ensures delivery of clinical policies to the Medical Management Platform (MMP) Team (for internal posting for nurses and
Medical Directors) and to Digital Communications (for posting on WellCare.com); includes auditing both access points to ensure accuracy.
Prepares Clinical Policy Update to notify the markets and leadership of Clinical Policy changes.
Assist with Vendor Management to ensure coding review and implementation including updating the Auth Lookup Tool (ALT),
Quick Reference Guides (QRG). Also serves as a liaison to vendors specific to external medical reviews.
Adheres to industry and company policies related to Compliance.
Coordinate and review activities to meet contractual, regulatory and, internal department standards.
Serves as a liaison between the Medical Management team to the Systems Integration team to ensure that coding related
inquiries are addressed as CCGs are uploaded to the medical management platform for medical necessity review by the UM team.
Cotiviti Atlanta, GA
Client Policy Manager 2016-2018
Manages client payment policies by ensuring client s payment policy is accurate, up-to-date and complete. Ensuring execution of client specific requests and acting as the internal and external client team liaison.
Reviews all documents and coordinates reviews with the Medical Directors
Conducts research and analysis for medical policy items.
Primarily responsible for the integrity of the client's medical policy rule set, including awareness of all client-related Medical Policy Project Requests, monthly review of Max Units, review of Health Plan rules, etc.
Primary driver of the Periodic Update Analysis and participates in monthly/quarterly client policy meetings:
Reviews clients’ payment policies for accuracy
Presents the policies for review and acceptance by the client
Provides direction on client understanding of medical policies
Reviews and identifies changes needed to client policies in order to maintain up-to-date and accurate medical payment policies.
Performs multi-faceted analytics in all data and report analysis
Applies project management principles in initiating, creating and managing projects
Reviews and analyzes client inquiries for clarity of intent, applying decisions for affected policies, maintaining information and communicating effectively with the client.
JSA Healthcare St Petersburg, FL
Sr. Claims Audit Analyst-Contesting 2015-2016
Perform in-depth data analysis and provider profiling to determine recovery opportunities from fraudulent, abusive or erroneous claims payment activities.
Conducts specials projects requiring high degree of confidentiality and expert knowledge of multiple departments within the company.
Acts as a team leader on large projects requiring coordination with multiple departments within and outside of the company.
Provider management with baseline peer review findings for tracking department quality to identify training deficiencies.
Analyzes trends to recommend process or operational improvements.
Assists with developing and maintain departmental policies and procedures.
Assists with developing training materials for the department.
Review claims for risk contracts for accuracy.
Acts as a mentor/SMW for all claims audit analysis.
WellCare Health Plans Tampa, FL
Supervisor, Claims Coding Team 2013-2015
Manages claims coding rule initiatives including the development of detail work plans.
Receives and logs requests of changes and appeals to committees ruling.
Maintains a library of all the existing and retired rules, the source of the rule and the implementation/retire date of the rule (by Market and by Line of Business)
Documents supporting authority for each claims coding rules by Market and by Line of Business (Master Grid)
Participate in cross-functional teams to address key claims coding rule issues facing the organization.
Administers communication to Markets and collect feedback
Evaluates change proposal from Clinical perspective, Financial perspective, and Claims operational perspectives; Prepare analysis of claims coding rule changes.
Seeks professional feedback from Health Services, Finance, and Claims on claims coding rule changes
Identifies coding error (e.g., up-coding, bundling/unbundling) and recommend correct coding of medical claims
Researches CMS/State laws and AMA guidance
Presents change proposal to committee
Communicates effectively to markets
Travels to providers/facilities as necessary, act as the face of the Claims Coding Team
Develops relationship with claims coding rule software vendors
Provides mentoring and guidance to Specialists and train less experienced staff
Support claims, configuration, PRT, and/or appeal & grievances teams as necessary
Discuss coding issues with finance and vendors to optimize payment
Accurately code records for appropriate reimbursement, i.e. Unlisted codes
Monitors associate performance and conducts counseling/corrective action procedures when required,
Provides significant input to performance evaluation, hiring and termination decisions for associates in work group,
Reviews time records, sets schedules and approves all vacation/time off requests for subordinate associates,
Conducts/coordinates new associate training in area policies/procedures and workflow processes
Coding Analyst March 2013-July 2013
Maintains a library of all the existing and retired rules, the source of the rule and the implementation/retire date of the rule (by Market and by Line of Business)
Documents supporting authority for each claims coding rules by Market and by Line of Business (Master Grid)
Participate in cross-functional teams to address key claims coding rule issues facing the organization.
Administers communication to Markets and collect feedback
Evaluates change proposal from Clinical perspective, Financial perspective, and Claims operational perspectives; Prepare analysis of claims coding rule changes.
Seeks professional feedback from Health Services, Finance, and Claims on claims coding rule changes
Identifies coding error (e.g., up-coding, bundling/unbundling) and recommend correct coding of medical claims
Researches CMS/State laws and AMA guidance
Presents change proposal to committee
Communicates effectively to markets
Travels to providers/facilities as necessary, act as the face of the Claims Coding Team
Develops relationship with claims coding rule software vendors
Provides mentoring and guidance to Specialists and train less experienced staff
Support claims, configuration, PRT, and/or appeal & grievances teams as necessary
Discuss coding issues with finance and vendors to optimize payment
Accurately code records for appropriate reimbursement, i.e. Unlisted codes
PCA Medical Group Tampa, FL
Health Information Manager 2012-2013
Audits and reviews medical documentation for appropriate ICD-9 and CPT coding.
Queries physicians when code assignments are not straightforward or documentation in the record is inadequate, ambiguous, or unclear for coding purposes.
Performs training and education for coding, documentation and claim payment guidelines, as well as addressing problems and issues.
Reviews CPT and ICD-9 codes annually for accuracy and implements changes, including charge ticket update by specialty.
Assists physicians and other providers with questions and problems related to coding, documentation and billing.
Assigns and sequences ICD-9-CM/CPT/HCPCS codes to diagnoses and procedures for documented information. Assures the final diagnoses and operative procedures as stated by the physician are valid and complete. Abstracts all necessary information from health records to identify secondary complications and co-morbid conditions.
Implemented new Electronic Heath Records system into wholly owned offices, including all training of office staff and physicians.
Quantitative analysis - Performs a comprehensive review for the record to assure the presence of all component parts such as: patient and record identification, signatures and dates where required, and other necessary data in the presence of all reports which appear to be indicated by the nature of the treatment rendered.
Qualitative analysis - Evaluates the record for documentation consistency and adequacy. Ensures that the final diagnosis accurately reflects the care and treatment rendered. Reviews the records for compliance with established third party reimbursement agencies and special screening criteria.
Transatlantic Healthcare Tampa, FL
Coding Analyst 2011-2012
Audits and reviews medical documentation for appropriate ICD-9 and CPT coding and documentation.
Queries physicians when code assignments are not straightforward or documentation in the record is inadequate, ambiguous, or unclear for coding purposes.
Performs training and education for coding, documentation and claim payment guidelines, as well as addressing problems and issues.
Reviews CPT and ICD-9 codes annually for accuracy and implements changes, including charge ticket update by specialty.
Assists physicians and other providers with questions and problems related to coding, documentation and billing.
Assigns and sequences ICD-9-CM/CPT/HCPCS codes to diagnoses and procedures for documented information. Assures the final diagnoses and operative procedures as stated by the physician are valid and complete. Abstracts all necessary information from health records to identify secondary complications and co-morbid conditions.
Follows appropriate policies, procedures and guidelines ensuring compliance with Transatlantic Healthcare, state, and federal laws, policies and regulations.
Quantitative analysis - Performs a comprehensive review for the record to assure the presence of all component parts such as: patient and record identification, signatures and dates where required, and other necessary data in the presence of all reports which appear to be indicated by the nature of the treatment rendered.
Qualitative analysis - Evaluates the record for documentation consistency and adequacy. Ensures that the final diagnosis accurately reflects the care and treatment rendered. Reviews the records for compliance with established third party reimbursement agencies and special screening criteria.
Analyzes provider documentation to assure the appropriate Evaluation & Management (E & M) levels are assigned using the correct CPT code.
Sanford Brown Institute Tampa, FL
Medical Billing & Coding/Medical Assisting Program Director 2007-2010
OSHA Compliance Officer
Managed over 45 instructors.
Reviewed, analyzed, and improved program curricula and syllabi for both programs.
Responsible for all student retention, maintained and exceeded monthly reentry budgets.
Chaired Medical Assistant and Health Insurance Billing and Coding faculty meetings.
Prepared documentation whenever advising a student or faculty member.
Responsible for recruitment, orientation, and faculty training.
Assured content and delivery of training is relevant to course study.
Support Director of Education with day to day operations.
Teach in both the Medical Billing & Coding and Medical Assisting Programs.
Coordinated certification examinations for Medical Assisting and Medical Billing and Coding.
On-site proctor for CBCS, CCS and CMA examinations.
Remington College Tampa, FL
Allied Health Department Chair/ OSHA Compliance Officer 2006-2007
Assisted in recruitment, orientation, and faculty training.
Managed over 32 instructors along with a large student body.
Responsible for scheduling certification examinations for all Allied Health Programs.
Taught and advised students in Medical Billing/Coding, Medical Assisting, and Pharmacy Technician programs.
Reviewed, analyzed and continually seek to improve and revise program curricula and syllabi.
Responsible for all faculty evaluations, as well as yearly reviews.
Developed plan of action to control student retention and re-enrollment.
Attended Program Advisory Meetings for all assigned departments.
Assisted in recruitment, orientation, and training of faculty.
Responsible for retention in all allied health programs, met or exceeded monthly goals.
Florida Career College/EduTech Centers Riverview, FL
Medical Director/ OSHA Compliance Officer 2005-2006
Managed over 20 instructors.
Reviewed, analyzed, and improved program curricula and syllabi.
Served as school’s externship supervisor.
Chaired Medical Assistant and Health Insurance Billing and Coding faculty meetings.
Prepared documentation whenever counseling a student or faculty member.
Assisted in recruitment, orientation, and faculty training.
Assured content and delivery of training is relevant to course study.
Scheduled and proctored certifications for Medical Assisting and Medical Billing and Coding.
Certifications:
CCS -Certified Coding Specialist
CPC-Certified Professional Coder
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