Health Information Medical Coding

Karon O’Brien

Lithonia, GA • ***********@*******.*** • 678-***-****

Certified Professional Coder (CPC) RHIT CPBS

Professional Summary

Results-driven healthcare operations leader with 30+ years of expertise in medical coding, payment policy, claims adjudication, and system configuration across government and commercial health plans. Proven track record in leading cross-functional initiatives, auditing reimbursement systems, and developing SOPs for compliance and payment accuracy. Skilled in CPT, HCPCS, ICD-10, EDI, and QNXT systems. Known for translating regulatory policy into actionable solutions that improve financial performance and data integrity. Collaborative, solution-oriented, and trusted SME in revenue cycle management and coding compliance.

Core Skills & Competencies

• Medical Coding & Auditing (CPT, HCPCS, ICD-10, ADA)

• Claims Adjudication & Configuration (QNXT, CES, Cotiviti)

• Medicare & Medicaid Policy Compliance

• Payment Integrity & Reimbursement Analysis

• SOP Development & System Optimization

• Provider Relations & Contract Codification

• Epic & Electronic Medical Record Systems

• HEDIS, HIPAA, CMS Guidelines

• SQL EDI Workflow Audits

• Remote & On-Site Team Collaboration

Professional Experience

Project Manager – Coder

Molina Healthcare, Inc. – Long Beach, CA Aug 2023 – Present

Lead coding oversight for Marketplace Line of Business (LOB), aligning benefit configuration with CMS guidelines.

Drive collaboration with Configuration, Payment Integrity, and Clinical Policy teams for policy accuracy.

Coding SME

Conduct audit reviews for high-dollar claims and benefit edit trends; ensure system integrity across QNXT and CES.

Developed SOPs for benefit interpretation and introduced documentation protocols improving audit readiness.

Lead Configuration Analyst

Molina Healthcare, Inc. Aug 2013 – Present

SME for QNXT configuration, CPT/ICD code updates, and clinical policy codification across all markets.

Led contract codification, fee schedule audits, and reimbursement analysis, ensuring claims compliance.

Authored and implemented best practices for configuration standards and system updates for Marketplace LOB.

Offered critical insight on policy implementation, prior authorization coding, and claims edit resolution.

Project Manager – Revenue Cycle IT

APEX Systems (Consulting @ WellStar Health) – Atlanta, GA May 2013 – Aug 2013

Managed Epic implementation and third-party application integration for revenue cycle optimization.

Developed project plans and testing protocols for coding workflows across the health system.

Manager – Payment Policy & Training

Peach State Health Plan – Atlanta, GA Sep 2012 – May 2013

Led payment policy implementation for Medicare and Medicaid LOBs.

Conducted coding audits and provider training, improving reimbursement accuracy.

Developed network communication and trained staff on federal/state billing compliance.

Sr. Medical Coding Project Analyst

WellCare of Georgia, Inc. – Atlanta, GA Mar 2009 – Sep 2012

Acted as SME for coding audits, payment policy evaluation, and HEDIS coding.

Conducted fraud & abuse audits, contract reviews, and ICD-10 transition preparation.

Medical Director Assistant

iHealth Technologies, Inc. – Atlanta, GA Jul 2007 – Mar 2009

Coordinated policy library updates and claims rule changes aligned with CMS policies.

Delivered SME support to medical directors and internal staff on coding compliance.

Healthcare Consultant

Independent Consultant – Atlanta, GA Jan 2006 – Jun 2008

Delivered interim revenue management services, billing audits, and coding support.

Designed and taught post-secondary medical coding programs.

Developed compliance programs and performed HIPAA training & documentation.

Education

B.S. in Health Information Management (Cum Laude)

DeVry University – 2023

A.A.S. in Health Information Technology (Honors)

DeVry University – 2013

Certifications

• Registered Health Information Technician (RHIT)

• Certified Professional Coder (CPC)

• Certified Physician Billing Specialist (CPBS)

Technical Tools & Platforms

QNXT • Epic • Cotiviti • SQL • Citrix • Microsoft Office Suite • Electronic Medical Records • CMS Portals

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