Health Information Medical Coding

Karon O’Brien, BSTM, RHIT, CPC, CPBS

**** **** ****** *****

Lithonia, GA 30058

Phone: 678-***-****

***********@*******.***

SUMMARY

Expertise and competence in over 30 years of extensive experience in writing Medical Policy & Business Rules, Medical Coding, Claims Adjudication, Auditing, Knowledge of Physician Reimbursement Guidelines and System Configuration. Strong knowledge in Government/Commercial/Affordable Care Act coding and billing guidelines including CPT/HCPCS, ICD-10 CM, and ADA coding as well as various prospective payment systems and regulations. Solid knowledge in Government/Commercial payer systems including but not limited to Commercial, Affordable Care Act, Medicaid, Medicare, HMO, PPO, and Managed Care. Maintain data integrity by the Standards of Ethical Coding as set forth by the American Health Information Management Association and adheres to official coding guidelines and conventions. Assertive and effective in communicating with individuals of diverse backgrounds and experience levels and problem-solving skills/solution oriented. Strong knowledge in Medical Terminology, Anatomy, Physiology, Pharmacology.

EDUCATION

DeVry University

Bachelor of Science Technology in Health Information Management (HIM)

Graduated with Honors (Cum Laude)

DeVry University

Associates of Applied Science in Health Information Technology (HIT)

Graduated with Honors

CERTIFICATIONS

Registered Health Information Technician (RHIT), Certified Professional Coder (CPC), Certified Physician Billing Specialist (CPBS)

AFFILIATIONS

AHIMA, AAPC, GAHIMA

TECHNICAL SKILLS

Microsoft Office Suite, Medical Coding, Configuration, EMR, 3M, Amethyst, QNXT, Facet, Citrix, Epic, Entry-Level SQL Knowledge, PEGA.

PROFESSIONAL EXPERIENCE

Molina Healthcare, Inc.

Long Beach, CA (Remote)

August 2023-Current

Project Manager-Coder

•Plans and directs Marketplace Benefit Requirements

•Monitors the benefit coding project from inception through delivery

•Assigns, directs, and monitors system analysis and program staff

•Review and implement new updated/changing Marketplace medical coding

•Participating in Marketplace Code Edit Trend Reporting

•Develop an understanding of current Marketplace Benefit Requirements working in conjunction with the Configuration Team.

•Audit System Configuration for Marketplace LOB

•Participation in weekly Marketplace Code Edit Meeting for Marketplace Approval

•Perform review on high dollar claims for Marketplace LOB

•Work with Payment Integrity Team regarding edits with CES and Cotiviti

•Build positive relationships between providers and Molina by providing coding assistance when necessary

•Review and Approve Monthly SAI Concepts for Payment Integrity

•Develop SOPs for Benefit Interpretation Team

•Develop and Implement Benefit Interpretation Requirement Document for the Configuration Team

•Responsible for supporting development, execution and ongoing management of a defined National Benefit Interpretation (BI) governance processes on behalf of the Marketplace (MP) line of business

•Supports leadership with process flow, documentation development and business decisions

•Monitors, log, and research member grievances to resolution or determination

•Creates documents with required coding information in order to accurately adjudicate claims and performs code analysis using claim reports

•Conducts extensive product research for compliance using Federal, State, and Local references

•Works closely with the MP Product, Ops teams and Healthcare Services / UM leadership & QNXT (MP) Configuration team in supporting BI management and submitting change requests

•Analyze requirements, planning, designing and implementing database solutions that meet or exceed challenging business needs

Molina Healthcare, Inc.

Long Beach, CA (Remote)

August 2013-August 2023

Lead Configuration Analyst

•Audit QNXT System Benefits

•System QNXT Marketplace Benefit Configuration

•QNXT System Configuration for New and Existing Benefits

•Audit Medical Policy Edits

•SME Coding

•Coding concept and claim research

•Reimbursement Analysis

•Contract Codification

•Fee Schedule Update and Review

•New CPT, ICD-10, HCPCS Codes Notification

•Contract Analysis

•Examining Clinical Policies

•Working with Clinical Policy Team on Policy Codification

•Work with UM on Prior Authorization requirements

•Development of Business Requirement Documentation for all Markets

•Assists with development of configuration standards and best practices.

•Lead the expansion and implementation of existing business Marketplace LOB.

•Participate in Projects for both Configuration and Corporate initiatives.

•Implementation and conversion of new and existing Health Plans

•Maintain configuration change request forms (CCRF) for quality audit purposes.

•Maintain and stay abreast of Medicare and Medicaid changes

•Special Projects with Medical Director(s)

APEX System

Atlanta, Georgia

May 2013-August 2013

Project Manager, Revenue Cycle IT (Consultant)

•Leads information systems design, development, and implementation projects for the WellStar Health System

•Creates system specific project plans, task sequencing, goals, deadlines, testing and implementation

•Develops and maintains associated project plan templates and supporting documentation

•Monitors resource utilization and costs

•Work with Third Party Vendors on Revenue Cycle Applications

•Epic Implementation

•SME Coding

Peach State Health Plan

Atlanta, Georgia

Sept. 2012-May 2013

Manager Payment Policy & Training

•Serve as the SME on CPT Coding, HCPCS, ICD-9

•Coding Auditing

•Revenue Cycle SME

•Serve as the SME on Medicare and Medicaid guidelines

•Provide business recommendations based on sound analytics to Senior Leadership

•Monitor and analyze Health Plan product lines for financial return, trends, opportunities for cost avoidance and operational efficiencies

•Assist in implementing new financial projects or monitoring activity

•Assist other management staff with finance programs and/or policies and procedures

•Attend/Conduct training seminars and conferences

•Develop all Network Communication relating to PSHP Policies

•Payment Policy Implementation for Medicare/Medicaid Line of Business

•Provide resolution of provider inquiries on unpaid or underpaid claims

•Contract Review/Auditing

•Participate in quality management projects as requested

•Implement Payment Policies based on state and federal regulations

•System configuration resolution, EDI, and UAT

•Compliance SME on state billing/coding issues

•Responsible for researching and monitoring federal regulations to determine new policy opportunities including reimbursement, medical or other payment policies

•Coordinator for ICD-10 implementation and deployment

WellCare of Georgia, Inc.

Atlanta, Georgia

March 2009-Sept. 2012

Sr. Medical Coding Project Analyst

•Serve as SME on Coding

•Coding Auditing

•Serve as SME for Medicare and Medicaid guidelines

•HEDIS coding SME

•Responsible for conducting in-depth analysis to identify cost-saving opportunities

•Responsible updating and maintaining requirements regarding billing and coding compliance

•Responsible for researching and monitoring federal regulations to determine new policy opportunities

•Develop Network Notifications regarding payment policies

•Work with market leadership and other key stakeholders regarding all company payment policies

•Work with Department of Community Health on current policies

•Work closely with Senior Operation Manager in GA, TX, KY Markets

•Oversee the evaluation and maintenance process vendor edits implementation

•Perform Payment Policy and Coding Audits

•Served as SME on compliance related issues

•Contract review and negotiation

•Project Management

•Conduct Fraud & Abuse Audits work with Compliance Director of Fraud Issues

•New Product Implementation

•Coordinator for ICD-10 implementation and deployment

iHealth Technology, Inc

Atlanta, Georgia

July 2007-March 2009

Medical Director Assistant

•Responsible and accountable for the coordination and management of multiple related projects

•Maintained continuous alignment of new and existing payment policy Library Business rules

•Recommendations to modify rules based on Industry updates and CMS Policy guidelines

•Coordinate recommendations with Medical Directors

•Worked with technical team environment on configuration

•SME to internal staff on coding guidelines

•Work with client on ad hoc data analysis to identify potential savings based on data evaluation

•Developed edits for implementation for Clients

•Developed edits for RAC

•Served as SME on claim processing and Professional Coding

•Identified potential saving opportunities in utilizing medical payment policies

•UAT/EDI

J Alexander & Associates, LLC

Atlanta, Georgia

June 1999-July 2007

Independent Consultant

•Interim Management for Billing/Revenue Department

•Conduct annual training in the area of Reimbursement, Customer Service and Coding

•Conduct billing and coding audits

•Reimbursement Analysis

•Perform contract Medical Coding (Inpatient & Outpatient)

•Perform Medical Billing Analysis, Revenue Cycle Management, Chart Audits, Billing Audits

•Develop Compliance & HIPAA Program Development & Implementation

•SME on coding assisting Attorney(s) with Qui Tam

•Revenue Cycle Improvement

•Teaching Medical Coding and Billing classes for Post-Secondary Institution(s)

•Maintain and created material for training programs and quality control monitoring tools

•Project Management

•Contract Coding

•Contract review and negotiation

•Producing Cost Reports

•Examining Payers Policies

•Minimizing patient denials

•Maximizing Reimbursement Compensation

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