Quality Assurance Risk Adjustment

Aymee Gonzalez Cruz

***** ** ***** **, *****, FL 33187 **********@*****.*** 786-***-****

Professional Summary

Certified healthcare auditor and medical coding specialist with 8 years of experience in coding and 4 years in auditing, risk adjustment, and quality assurance. Expert in medical documentation analysis, regulatory compliance, and staff training. Detail-oriented, self-motivated, and committed to enhancing accuracy and driving continuous improvement in healthcare operations.

Education

Certified Professional Coder – CCM Coding Academy, Coral Gables, FL (Jan 2017)

Bachelor of Biblical Studies – Global University, Springfield, MO (Jan 2016)

Pharmacy Technician – Instituto Politécnico de la Salud Fe del Valle, Havana, Cuba (July 1995)

High School Diploma – IPUEC 'República Popular de Angola', Havana, Cuba (July 1992)

Certifications

CPMA – Certified Professional Medical Auditor (Nov 2019)

CDEO – Certified Documentation Expert Outpatient (July 2018)

CRC – Certified Risk Adjustment Coder (March 2018)

CPC – Certified Professional Coder (Jan 2017)

Skills

Medical Chart Auditing & Documentation Improvement

Risk Adjustment & Coding Compliance (ICD-10, CPT, HCPCS)

EMR Systems: ECW, NextGen, Intergy, Lytec, MDVita, CARE360

Team Leadership & Training

Regulatory Knowledge (CMS, HEDIS, HIPAA)

Microsoft Office Suite

Professional Experience

Quality Assurance Auditor - Clinical Care Medical Center / Humana (Feb 2020 – April 2025)

- Conduct retrospective audits of medical records for coding accuracy and documentation quality.

- Ensure compliance with CMS and ICD-10 standards; identify coding/documentation errors.

- Provide coder and provider education on risk adjustment and clinical documentation improvement.

- Lead training for new employees on auditing and risk adjustment principles.

- Support implementation of corrective actions and Supplier Audit Plans.

Certified Professional Coder - Conviva Solutions Care Center (Feb 2019 – Jan 2020)

- Coder and reviewed patient encounters, identifying HCC and care gap opportunities.

- Collaborated with providers to improve documentation and coding compliance.

Billing & Coding Specialist - Cano Health (Aug 2017 – Jan 2019)

- Assign ICD-10-CM/CPT/HCPCS codes; ensured claims accuracy and compliance.

- Conduct chart reviews and HCC/HEDIS analysis.

- Seek clinical documentation and to make recommendations to physicians based on their overall medical observation and documentations of medical records

Area Medication Manager / Pharmacy Technician - Various Clinics and Hospitals, Havana, Cuba (Sept 1995 – Dec 2014)

- Supervised pharmacy operations, medication preparation, and inventory control.

- Ensured compliance with pharmacy protocols and ethical standards.

- Participated in therapeutic committees and managed staff training and scheduling.

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