Marcia Catherine Mackin-Grimes MPA, RHIA

New Jersey 08753

Phone: 732-***-****

Email: adxu8u@r.postjobfree.com

EXPERIENCE:

Director, Health Information Management/Systems and Privacy Officer and Coding Manager for services multi-site, teaching facilities: Medical, Comprehensive, Rehabilitation, Psychiatric, Oncology, Cardiology, Inpatient, Inpatient Rehab, Pharmacy, Outpatient, Group Practices/Medical Offices, Same Day Surgery, Long Term Care, Research-Pediatrics, Adults (Cancer, Autism, HIV/AIDES), Trauma, Vendor Management. Daily Operations and Coding and Reimbursement, Calculating RVUs, Clinical Documentation Improvement, internal and external audits, budgets – Coding of Inpatient, Inpatient Rehab/ Outpatient Rehab, Same Day Surgery, Emergency Room, Oncology, Lab and Radiology, Disaster Recovery, prevention of Stark Law violations – self referrals, all Coding Audits / Billing Audits, CMI preparation, CDI, appeals Medical Necessity, Denials, DNFB Review and MS/DRG - DRG Validation, Charge Master, Performance Improvement, Revenue Cycle Management Team member, implementation of the electronic medical record (Medical/Clinical) and revenue cycle modules (Build, Testing, Training, Education), organization wide projects as EMTALA, Adverse Events (HACs), POA, RAC, OSHA, UR, PRO, IRB’s, Leap Frog, Streamline Health, Preparation Pandemic; Safety Medical / Clinical, HIPAA (Privacy and Security), CMS, OIG Work Plans, JCAHO, DNV, CARF, Root-Cause Analysis, Quantitative Analysis, Qualitative Analysis, Statistical Reporting and Research, Disease Registry(s), Process Management, Utilization Review Audits, Medication Administration / Medication Reconciliation-Billing Audits and ICD 10 Disease Classification Dictionaries, CPT/HCPCS audits, verification NDCs, LCDs, DEA and the 5010 preparation- testing, training, education and audits, addressed patient services complaints. Strategic initiative including ground floor development of new IP Rehab Hospital and OP Rehab sites expansion, other.

Cooer Health, Camden, NJ 2/03/2020 – 02/15/2023

Coding Manager

All Management responsibilities; Rounding, Webex Training of Coders. Coordinate, code, monitor, report accounts by levels of care in assigned Work Queue(s) and perform periodic audits with feedback; statistical reporting. Reported Trends – identified Root Cause addressed with Teams for correction. Develop education and training. Enhanced coding quality and/or initiates performance actions to correct coding and create process for delinquencies / deficiencies. Ensured 95% accuracy rate or better. Full Revenue Cycle. Claim Edits. Charges. CDM. all Denials, Front End Denials; Retro, coding issues and process, security and accuracy of patient records. Current with software and network access and security issue for inhouse and vendor staff. EPIC Upgrades; testing and live. Pandemic Committee; Medical Clinical and non-clinical preparation with focus on Safety. Ensure focus on quality while maintaining 95% Accuracy Rate. Self Disclosures; identification of coding errors. Adhere to Code of Conduct and Ethics, Coding Ethics and Patient Privacy, Payor Policies and all Federal / State Regulatory requirements and Coding Guidelines.

Create policies and implementing changes, coordinating with other managers and with physicians, reviewing departmental procedures, and evaluating Medical the effectiveness of coding staff. Also facilities where patient data may be used in studies or research, Responsible for insuring that data is available to authorized personnel. Other responsibilities include but are not limited to working with Compliance, Medical, UM, Case Management and CDI Departments adhering to current coding practices and guidelines; Professional and Hospital. Conducts coding audits and provides educational programs based on auditing results. Effectively uses abstracting databases, internal and external audit results, QIO reports and revenue cycle edit/denial information. Inpatient and Outpatient Coding Edits; Claim Edits. CMS RAC Appeals. Internal / External Claims Edits review and correction of Denials; report Trends. Effectively interacts with both coding staff and different levels of management throughout the healthcare system; incomplete or in need of diagnosis clarification / procedure clarification, missing information, missing charges, etc. and cannot be coded, generate a Coding Query in EPIC addressed to the responsible Provider.

1.Ongoing record audits to verify coding and grouping accuracy

2.Performs educational sessions for coding specialists.

3.Build and review accounts audited by Streamline Health.

4.Reports on coding and grouping accuracy based on audit results; Serves as an expert resource for all coding staff; in-house Coding / Vendors.

5.Troubleshoots coding issues; reporting trends.

6.Work directly with front end Team addressing PreAuth Denials; Retro Auth Process.

7.Accurately sequence principle diagnosis and procedures, complications and comorbid conditions on inpatient and outpatient accounts.

8.IP; Verify Medical Underlying Conditions / Comorbities / Manifestations are sequenced according to regulatory requirements and coding clinics, procedures and charges; in-house / Vendors. Verify Payor Policies with Billing and Revenue Integrity.

9.Verify Social Determinants are coded

10.Provides guidance to other departmental staff in identifying and resolving coding issues or errors; Claim Edits.

11.Coding Audits for review and correction of accounts, accurately assigning ICD-10-CM/PCS and CPT/HCPCS codes to complex outpatient encounters.

12.Verification of and correction of Revenue Codes.

13.Audit use of appropriate modifiers: Medicare / Medicaid

14.Analyze and resolve claim denials that are rejected by edits from the Patient Accounts department.

15.Prepare monthly meetings for OP Coding Staff: Revenue Integrity, Billing, HIM Coding.

a.Share results of audits, new enhancements, proposed changes from Team w/IT.

16.Maintain the national standards for coding accuracy and internal standards for productivity.

17.Manages coding operations for hospital, Clinic, Medical Offices, Ancillary Services, etc.

18.Maintains responsibility for coding services for hospital-based trauma encounters, surgical and office-based encounters as well as denial management for both services and/or physician services.

19.Employee issues and to work with HR Business Partner when an employee(s) do not meet the Department expectations while adhering to the Cooper Health process for Disciplinary Action.

20.Other; special Revenue Cycle Projects, Coding, Claim Edits, etc.

21.CMS RAC Appeal Letters. Review and correct IP OP internal / external Claim Edits; Denials.

Meadowlands Hospital, Secaucus, NJ 2012 - 2018

Director, Health Information Management Systems and Coding Manager, Privacy Officer

Acute Care – 230 Bed Teaching Facility: Inpatient, Inpatient Rehab/Outpatient Rehab, Pharmacy (Medication Administration / Medication Reconciliation –Billing Audits ) Outpatient, Oncology, Same Day Surgery, Emergency Room, Lab and Radiology, Medical Offices, Outpatient Infusion.

Team player of Revenue Cycle. Disaster Recovery, Clinical Documentation Improvement Program working with VP Revenue and team, Case Management addressing Physician Documentation and Medical Necessity resulting in reduction of denials and successful appeals. Review, correction, training and education of Registration errors on assignment of correct levels of care reporting findings to VP Revenue and Case Management. Training and Education of rotating Medical Residents on applications and documentation requirements resulted in more timely completion of accounts with improved rates of compliance for coders and reduction in Coding Queries. Revenue Cycle Management working with Billing Department Failed Claims and Failed Bills. Brought DNFB down by audits, identification and correction of accounts for clean claims. Audit, review and corrections mapping of 3M and Revenue Cycle Modules resulting in clean revised claims and increased revenue. Successful audits for Leap Frog.

Accurate coding and accurate review and correction of accounts coded in error with all levels of care: Inpatient, Inpatient Rehab, Emergency Room, Same day Surgery, Outpatient Chemo Infusions. ICD 10 preparation, training and education for Coders, Case Management, Physicians, Medical Residents, Billing… ongoing with successful rates of compliance. Working directly with VP Revenue, organized and developed OP Oncology services, required documentation / physician orders / medications meeting compliance. HAC identification, review and reporting to VP Revenue and Clinical Team with accurate reporting. Review, identification and correction of DRG errors with Medicaid Accounts. Medication Administration (BCMA) and Medication Reconciliation audits, identification of errors, error corrections to charges in B/AR for clean revised claims…reporting results of errors for ongoing education and training to VP Revenue. Wrote appeals for medical necessity and DRG validation.

Tumor Registry was brought current from being 2+ years behind on reporting. Review of all accounts by ICD10 PCS/CM Codes for reporting of all Open Procedures, HACs, Congenital Anomalies, Cancer cases. Cancer Tumor Registry on documentation issues with daily collaboration with the Medical Oncology Department with successful outcomes in documentation requirements for Tumor Staging, Qualitative/Quantitative Data Analysis, Adverse Events, Coding and State Reporting. All Statistical Reporting to Physicians, Pharmacy, Board.

IT Systems Development with Medsphere/CareVue (EMR), 3M, MediTech revenue, conversions, build, testing and training. HIPAA Investigations and resolve, Centralized ROI resulting in fewer breaches paper and electronic. Successful implementation of Patient Portal. CPOE Meaningful Use. Successful upgrade for Physician Countersignatures for Physician Order in a Teaching Facility. Successful builds for MediTech Revenue Cycle Modules for HIM, Coding and Reimbursement and Scanning. Successful 3M Training for go-live 06/01/15. HIPAA Investigations (Privacy and Security)

Successful CMS, OIG Work Plan, DOH, EMTALA, CARF, JCAHO, OSHA, RAC, Leap Frog, and DNV Surveys for HIS,etc.

Handled all review and preparation of cases for litigation with court appearance. Worked directly with VP Revenue.

Consultant – KForce 2012 – 3 months Interim System Director, Health Information Management Services

Multi-site Acute and Inpatient Rehab

Warren, Ohio

Healthcare Vendor Contracts, Compliance

HIPAA Privacy and Security

Revenue Cycle – monitoring and addressing issues impacting DNFB

Legal (Malpractice) Medical Record Reviews

Electronic Medical Record / Electronic Legal Medical Record

RAC Process with training and education to the Medical / Clinical Staff, Performance Improvement, Risk Management, Finance, HIMS

Glens Falls Hospital, Glens Falls, NY 2010 to 2011

Director, Health Information Management Services

Acute Care facility and Outpatient Services, Medical Offices

Successful re-development of Clinical Documentation Improvement Program resulting in timely coding and billing, RAC implementation process with reporting and accountability and timely response with documentation to support, mandatory process for collaboration addressing errors with Data Integrity and Registration Issues, development of process for Medical Staff Credentialing and Privileges with HIMS Data Integrity to eliminate coding and billing errors. Successful audits with use of SMART application. All Statistical Reporting to Physicians, Nursing, Chiefs.

Successful development of relationships with Medical / Clinical Staff, Pharmacy, Surgery, Emergency Room, Outpatient, Physician Practices, Radiology, Laboratory an0d all other services. Successful development of non-compliance grid listing items (documentation, Code 44, Medical / Clinical requirements)…this was submitted to the Medical Executive Committee for suggestions for revisions to the Medical Staff By-laws, Rules and Regulations on Credentialing, Privileges, for Medical / Clinical / Allied Health Professionals. Medical Staff By-laws Rules and Regulations were revised within the one month of presentation by the four Section Chiefs…Medical Directors. Successful revisions to workflow and documentation requirements for Surgical Procedures working with Medical / Clinical / Surgeons / Outpatient Physician Group Practices, Pharmacy, etc for improvements in specificity of documentation, cancelled visits, stop orders, cancel orders impacting coding and reimbursement. Successful on informing / educating the Providers and HIMS Coders with regard to the above. Successful on initial retraining and re-education of HIMS Coders based on coding guidelines. Successful in providing e-access to off-site coders. Successful workflow analysis organization wide for accountability for use of documentation flow for compliance and accountability. Cancer Tumor Registry on documentation issues with successful outcomes in documentation requirements for Tumor Staging, Qualitative/Quantitative Data Analysis, Adverse Events, Coding and State Reporting. RAC Audit preparation, training and education on Medical Necessity and Claims. Worked directly with all external auditors…QHR, Insurance Companies. Medical Record reviews on Code 44 with Clinical Staff. Worked directly with Physician Practices for improvements and corrections in the Charge Master with success

Internal / external audits, CMS, DOH, EMTALA, RAC, HIPAA Investigations (Privacy and Security), HACs, JCAHO, etc.

Children's-Specialized Hospital, 2006 – 2010, Mountainside, NJ

Director, Health Information Management Services and Privacy Officer

Comprehensive Rehabilitation Hospital – Pediatric, 13 sites and new IP Hospital (strategic initiative), 130 bed, Inpatient, Outpatient, Long Term Care, Research, Schools, Physician Group Practices/Medical Offices, Medical, Dental, Psychology, Psychiatry, PT/OT/Speech, Audiology, other

Successful opening of 2 facilities (Strategic Initiatives) for the new hospital and Psychotherapy Facility in New Brunswick in accordance to NJ State Regulations. Development of new departments with collaboration, training and education, development of new Job Descriptions and correct coding according to coding guidelines. Standardization of Practice; communication through new Policies and Procedures with regard to Coding and reimbursement, Legal Aspects, Release of Information, Privacy, Security, Medical / Clinical / Therapy / etc., documentation requirements. Retrospective Medical Record Reviews reporting to Medical / Clinical Staff and Leadership. All Statistical Reporting to Physicians, Pharmacy, Chiefs.

Revenue Cycle Management Committee for improvement on work flow, documentation specificity, compliance and correct coding. Developed of process for handling all Business Associate Agreements multi-site monitored process. Charge Master Clean up with collaboration, training and education, continuous audits and submitting of results with action plans. Qualitative/Quantitative Data Analysis, Adverse Events, Coding and State Reporting. Successful implementation and staff training on 3M Application for Coding and Reimbursement. Coding and Reimbursement: Coding all specialties, Staff training, Denials Audits, Coding Audits, Medication Administration and Medication Reconciliation, CDM Cleanup for all specialties with training and education. Retrospective chart reviews of Medical Staff, Nursing, Ancillary services on documentation requirements resulting in high rates of compliance and high accreditation scores; passing surveys. Handled all audits for JCAHO, CARF, CMS, State, Insurance Companies, OSHA, Legal, other with great success on findings affecting coding, billing and compliance. Prevention of Stark Law violations – self referrals.

New and revised policies and procedures for organization and department including HIPAA Privacy and Security resulting in standardization of process and centralization of requests.

Organization wide Super User for MediTech go-live: Clinical Documentation/Coding, E&M Compliance Seminars Team Leader for several Modules, direct participation with Medical and Clinical Modules defining workflow from Scheduling to Billing, wrote all Medical and Clinical Documentation Templates in accordance with Regulatory and Accrediting Agencies. Worked directly with CIO on consistency and standardization of Privacy and Security Policies and Procedures, major projects related to organizational workflow for the EMR/ELR, Pharmacy for corrections in Units for the purpose of Coding and Reimbursement.

Handled all legal aspects and release of information including preparation of cases for litigation. Worked directly with follow-up and follow-thru to VP HR / Risk Manager and Legal Counsel in possible, pending and ongoing litigation with Court interactions.

Direct participation with auditors: URO, PRO, CMS Medicare and Medicaid Audits, State, Insurance, HIPAA Investigations (Privacy and Security), JCAHO. CARF Billing Audits with reduction of appeals; Revenue Cycle, Medical Necessity Review… CPT-4, ICD-9, HCPCS. (all services and Clinical Documentation Improvement)

Successful reporting of all state requirements on FAS, Congenital Anomalies. IRB for Autism working directly with Medical Director.

Bergen Regional Medical Center, Paramus, NJ 2004 – 2006

Assistant Director, Health Information Management Services, Assistant to Privacy Officer

1200 bed academic medical center

Handled all external audits…CMS, State, Insurance Companies, URO, other working with Medical / Clinical / Lab/ Radiology / Pharmacy / Psych, Finance and all services and manual Medical Records to capture all treatment history(s)

Handled all legal aspects and release of information including preparation of cases for litigation. Worked directly with Legal Counsel in possible, pending and ongoing litigation. Handled all breaches in security and privacy

Lead for JCAHO Survey with results of 99.0%. Handled all audits for JCAHO, CARF, EMTALA, CMS, State, Insurance Companies, OSHA, Legal, other with great success on findings affecting billing and compliance. Gap and Risk Analysis organization wide with successful development of new Policies and Procedures with training and education…worked directly with CIO IT/HIS Staff and other Department Heads. Gap and Risk Analysis organization wide with successful development of new Policies and Procedures with training and education…worked directly with CIO IT/HIS Staff and other Department Heads. HIPAA Investigations (Privacy and Security), Direct involvement of testing of applications enhancements and upgrades. Work flow analysis for the HIMS Department and relationship with organization. Work Flow analysis of Emergency Room (Medical to Psyche) with successful rate of compliance based on 100% Medical Record Review. All Statistical Reporting to Physicians, Nursing, Chiefs.

Strong Committee involvement for Risk and Gap Analysis organization wide, JCAHO, HIPAA Committee, Medical Transcription Systems Meeting, Hospital Medical Systems and Applications Committees, Medical Record Committee, Clinical Pertinence Committee, Operations Committee, Performance Improvement Committee, Quality Improvement Committee, Utilization Review Committee, Medication Reconciliation Committee.

HIMS Staff restructure involving the Outpatient Clinics impacting documentation and Coding of Medical Records. Reduction in Coding Queries. Reduction in Days for Outpatient Coding. Concurrent Coding with emphasis on documentation requirements and medication administration and billing compliance. Daily collaboration with Finance / Billing / Registration for development of an efficient process ongoing to reduce denials.

Retrospective chart reviews of Medical Staff, Nursing, Ancillary services on documentation requirements. 100% chart audits: Inpatient, Outpatient, Emergency Department, Restraint and Seclusion, medication administration, medication reconciliation… resulting in high rates of compliance.

Passaic County Community College 2004 – 2007approx., Paterson, NJ

Adjunct Professor, Health Information Technology

State of NJ, Department of Military and Veterans Affairs, NJ 2003 – 2004

Manager/Director, Medical Records 2003-2004

Consultant 2004-2007

Long Term Care, Nursing Home – Adult, 350 beds, Medical, Pharmacy, Lab, PT/OT/Speech, Dental, Alzhiemer’s Units

Standardized the workflow of patient information with Medical / Clinical Staff and Nursing Unit Secretaries and Billing to meet compliance with Federal, State Regulations, accurate concurrent coding and billing. Medical Record Reviews reporting results to Medical / Clinical Staff, Leadership and Performance Improvement. Focus of regulatory compliance of Medical / Clinical documentation.

Successful implementation of NJ State Archiving application. Collaboration with Nursing for MDS submissions for Medicare. Work flow analysis on flow of documentation for treatment of Residents transferred to other facilities and back. All Statistical Reporting to Physicians, Dentists, Therapists, Pharmacy, Administration.

Member of the Medical Records Committee, Operations Committee, Revenue Cycle Committee, HIPAA Committee

Atlanticare Health System, 2000 – 2002, Atlantic City, NJ

Assistant Director, Health Information Management Services

Trauma Center, Acute, Multi-sites(2 Hospitals, multi-op) Adult – Pediatric – Newborn – Infant, 500 beds, Inpatient, Outpatient, Trauma Clinic, Ancillary Services, Medical, Oncology, Psychiatric, Cardiology, Urology, PT/OT, other

Change Management Committee with IT/HIS on Cerner PowerChart enhancements and upgrades, Medical Record Review Committee, Tumor Board/Tumor Registry Committees, HIPAA

Working directly with Cancer Tumor Registry on documentation issues with daily collaboration with the Medical Oncology Department with successful outcomes in documentation requirements for Tumor Staging, Qualitative/Quantitative Data Analysis, Adverse Events, Coding and State Reporting. All Statistical Reporting to Physicians, Nursing, Psychiatry, Therapists.

Handled all external audits…CMS, DOH, EMTALA, Insurance Companies, URO, OSHA. Medical Record Review Meetings – lead monthly Medical Record Reviews for all services and submitted all results to Medical Staff and Leader. Successful JCAHO Survey results meeting documentation requirements.

Handled all legal aspects and release of information including preparation of cases for litigation reporting directly to Legal.

MIDS Transmissions weekly– electronic transfer of claims…worked error reports and audited Medical Records resulting in clean claims (Credentialling, Registration / Insurance errors and missed codes), worked directly with the Coding Manager on documentation issues that impacted coding that lead to successful improvements in timely coding of Medical Records. Direct training and education of e-signature to the Medical / Clinical Staff and Residents ongoing. Performed all retrospective chart reviews for reporting. Direct participation from site to site on regulatory compliance of all Medical Record Documentation with training and education. Direct involvement of testing of applications enhancements and upgrades. Management Daily Operations within Health Information Management Services including Correspondence and Transcription and address documentation and billing errors for Coding. Worked directly with Medical Staff Credentialing specifically on Physician Privileges.

Committee involvement for the Implementation of e-signature documentation / applications for the Medical / Clinical Staff, JCAHO, HIPAA Committee, Medical Transcription Systems Committee, Hospital Medical Systems and Applications Committees, Medical Record Committee, Cancer Committee, and Tumor Board, Change Management Committees IT/ HIS, Organization wide Operations Committee, Medication Reconciliation Committee, HIPAA Committee – successful preparation with the team on training and education of the Privacy / Security Regulations.

Raritan Bay Medical Centers, 1998 – 2000, Perth Amboy, NJ

Clinical Data Analyst

Acute, Multi-sites, Adult – Pediatric – Newborn – Infant, 500 beds, Inpatient, Outpatient, Research, Ancillary Services, Medical, Oncology, Psychiatric, Cardiology, Urology

QuadraMed, Health Information Services Division, 1996 – 1998, New Brunswick, NJ

Health Information Services Account Representative

Physician Practices and Outpatient Services: Multi-sites, 75 specialty practices and Ancillary Services HIP NJ

TECHNICAL SKILLS

IT/HIS – upgrades, conversions, building, testing, implementation, training, education of McKesson Paragon and Star/ EMR, MedSphere/CareVue, Cerner PowerChart, Meditech, EPIC, SoftMed, Milliman, GEIDX, 3M,SNOWMED, QuadraMed, Emscribe/Trucode, Navigant, Nuance, SMART IP/OP, Gaffey, Emdeon, Medical Manager, FloTrans, AlphaSystems BCMA, all Microsoft Office, e-Clinical. Prior experience with Mainframe/ Mini-mainframes report generating SAS, SPSS… other.

CERTIFICATION EDUCATION

MPA – Health Services Administration, Kean University, Union, NJ

BA – Health Information Administration Kean University, Union, NJ

RHIA, American Health Information Management Association

ICD 10 AHIMA Academy

Member: AHIMA AAPC

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