Medical Coding & Claims Audit Specialist

S. VALENCIA TYRELL-BA, CPC, CBCS, PBT, CPMA

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

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Skills and Ability:

Project Management skills, trained, oriented, and provided leadership in quality customer service. Planned, managed, supervised, and counseled 11 subordinates. Liaison for major insurance companies, including but not limited to: Blue Cross, Aetna, Cigna, UHC/Optum, ARC-CPR instructor certified/trainer, Phlebotomist, Medical Coding Specialist, Auditor, NHA Certified

Education:

AAPC certification- CPC/CPMA-2025

NHA certification-CBCS-2025

Doctors Help, Phlebotomy Certification 2018

Strayer University BBA, 2011-2015, GPA 3.5

The University of District Of Columbia Medical Billing/ Coding (Workforce Dev. Program): Graduated 2013-2014, GPA of 4.0

Paul Lawrence Dunbar Senior High School- Washington, DC

Employment History

CareFirst BCBS- (Remote)-Claims Resolution Specialist III/Medical Coder/DME Auditor, 09/2021-01/2026

Monitors and fosters ongoing communications with government agencies regarding the status of claims.

Documents and updates internal database based on daily contact of select members of assigned applicant groups and application evidence requirements, i.e., work activity, medical condition, medical history, and documentation where evidence is required.

Writes appropriate, non-leading queries for Quarter reports.

Manage accounts receivable, including follow-up on unpaid claims and handling medical collections.

Collaborate with healthcare providers to clarify any discrepancies in patient information or billing.

Reviews inbox for daily inventory queues and identifies missing evidence.

Providers are placed on pre-/post payments for review daily.

Performs claims adjudication for complex medical claims.

Performs regular auditing,

Meets productivity standards on the number of adjudicated claims.

Researches contract terms/interpretation and compiles necessary documentation for denial reason validation.

Maintains quality and productivity according to client requirements

Abstracts, codes, and assigns the necessary demographic and clinical data elements required.

Generates weekly Claims Resolution reports for management by the schedule set by the supervisor.

Generates weekly Provider Claims Resolution logs for Provider Education purposes. Interfaces with the Organization's personnel, including fellow team members, supervisors, managers, and customers, while maintaining claims integrity.

Adheres to all federal laws and company policies regarding confidentiality of privileged patient information.

Works closely with the Medical Management team on the authorization process and auditing.

Adheres to company Human Resource policies and understands daily company work requirements.

Update job knowledge by participating in educational opportunities.

Inpatient/Outpatient coding/FWA/Analysis claims

Enhances the organization's reputation by accepting ownership for accomplishing new and different requests, and exploring opportunities to add value to job accomplishments. Other duties as assigned

Optum Health UHG-(Remote) Claims Analyst, 05/2023-03/2024

Evaluating and Processing insurance claims with precision and accuracy

Examine claims to determine their validity and to ensure that payouts are made following policy terms and regulatory requirements

Ability to read claims reports and EOB

Query Writing and reviews

Input ancillary charges into the billing software in accordance with protocol

Ability to complete QI training and participate in refresher training

Analyze documentation in conjunction w/IP/OP

Data interpretation

Medicalincs-(Remote)-Revenue Cycle Manager, 06/2022-01/2024

Processing payments and claims for the organization.

HIPAA Certified.

Review insurance claims to ensure all claims are paid on time.

Teaching and Trauma for providers and staff

Attend and lead weekly touchpoints with the SIU prepayment team

Responsible for all facets of medical billing and accounts receivable management, including charge entry.

Payment posting, customer service, and follow-up following practice protocol with an emphasis on maximizing patient satisfaction and profitability.

Oversees crucial tasks such as payment and collections within the healthcare industry.

Answered Prayers Therapy (Remote-Part-time) Administration Asst., 07/2022-11/2023

Process claims and payments

Monitor the billing and coding

Call insurance for verification of the patient’s eligibility in addition to getting authorization for services

The Mecca Group LLC, Contractor(Remote)-Billing Specialist, 05/2020-11/2021

Prepare and enter invoices into the AP system for multiple entities

Process weekly invoices for clients to ensure that transactions are processed accurately.

Ensure transactions comply with financial policies and procedures.

Investigate and resolve all discrepancies associated with insurance billing and coding procedures.

Assist the CFO directly with maintaining accounts and vendor inquiries.

Assist in the preparation of monthly financial reports.

School coding, IP/OP coding/Analysis

Utilizing accounting software

Quality Assurance

Documentation review

Clear Speech & Language Services LLC, Contractor(Hybrid)-Business Manager/Billing and Coding, 04/2019-08/2021

Organize office operations and company policies

Prepare applications for potential employees

Maintenance of safety procedures for clients.

OSHA Complaint

Complete intake information from the phone of potential clients

Order department supplies and enter any required purchase order or check requisition into eCW

Manage executive schedules, calendars, and appointments

Managing office services by ensuring office operations and procedures

Develop and implement office policies

Establish office handbook for clients and employees

Allocate tasks/assignments and monitor employees’ performances

Responsible for staying current on all HIPAA compliance and State compliance

Maryland Specialty Group Office Management/Patient Care Coordinator/Billing and Coding/AR/AP, 10/2017-04/2019

Creating and editing PowerPoint slide decks,

Budgeting

Ordering supplies

Understanding the financial background of the office

Marketing or handling public relations

Schedule growth meetings for HCC colleagues, set up teleconference meetings

Fulfilling the role of a human resource, including hiring staff

Creating procedures for dealing with patients

Overseeing staff duties, filing into facilities work orders, IT work orders, etc.

Help the coordinator and ensure patients understand every aspect of their care while also working with the administration to create policies and make decisions that are in the best interest of patients.

Developing and coordinating patient care programs.

Processing health insurance claims for healthcare facilities. Enter the correct codes into patients’ EHR/EMR

Reading and analyzing patient records, all in accordance with the HIPAA law and bi-laws

Evolent Health - Contractor-Remote 4/2016-09/2017

- Clinical Quality Educator (Coding/Auditing/Educating)

Correlating coding accuracy with correct HCC assignments.

Reviewed Medical Records/PAF to determine record support for claims billed.

Conducted/documented physician chart audits(research and presentation)

Educating and training to improve (Risk Adjustment Factor) RAF scores.

Implement education and provide formal training to staff as needed, including coding compliance

Analyzes data to prioritize educational reviews

Create Policy and Procedures to be used within the department to support Best Practices

Maintain the strictest confidentiality based on the HIPAA privacy policy

Suggested how to adjust claims based on the investigation during the review process.

ICD-10 coding

United Health Group/Optum- Medical Services (FWAE)

Refer tips /allegations on (Fraud/Waste/Abuse/Error)

Identified w/misrepresentation of physician coding errors.

Services billed were not rendered.

Locating billing for services that were not ordered.

Physicians falsifying or altering documents

Identifying physicians billing for services that were rendered.

Locating unlicensed physicians who are billing for services that were not ordered/rendered.

Identifying duplicate claims/bills for services rendered.

Identifying suspicious “out of country’ services.

United Health Group- Contractor- Remote Coder Medical Biller/Coder, 07/2015-04/2016

Posting International/National Medical charts for UnitedHealth Group

HCC Coding * PDF Rejects *

ACA Coding *SLR Recording *HQPAF DX Coding *ACA Hospital Chart Review * Gemstone

Claims Verification

Medicaid Coding

Claims Rejection/ rebilling coding

Annapolis Billing Services, Annapolis, MD (Part-time) Billing Specialist/Coder, 05/2014- 05/2015

Posting payment/charges for major insurance companies

HCC Coding

CPT Coding

DME Coding

Reviewed Medical Records to support billing claims

Adherence to state/federal/compliance policies and reimbursement policies.

Braham/Chesapeake Consulting (Part-time) Sub-Contractor (Guam) Remote Coder

Medical Auditor/Billing Coder, 10/2014- 07/2015

Examine medical records to ensure the accuracy of billing and payments.

HCC Coding

Rebilling for audit purposes.

Claims Rejection/Correction and billing back out for payment.

Verisk Healthcare, Richmond, VA (Part-time) Contractor (Remote Coder) Billing Specialist/Coder/Auditor, 07/ 2013- 11/2014

Coding international Medical Accounts

Coding insurance profile

HCC Coding

ICD-10 coding

Secure Medical Urgent Care Center, Beltsville, MD Billing Specialist/Coder 04/ 2008-06/2013

Manage third-party administrative accounts

Manage healthcare corporate accounts

Compile, collect, develop, create, and analyze summation reports

CPT Coding

Manage insurance profile for all major insurance companies

Manage accounts payable/receivable

Manage charge entry and payment posting

Workshops:

Powerful Telephone Tips, How to Give and Receive Criticism

Communicating for Results(How to be Clear, Concise, and Credible

How to Juggle Multiple Priorities,

How to Organize and Maintain Files and records

How to Deal With Negativity in the Workplace

Negotiate to Win: Get What You Want From Customers, Clients, Co-Workers, and Colleagues

How to Manage Conflict, Anger, and Emotion

Conflict Resolution, Behavior Management

Crisis Intervention, Managing stress in the workplace

Speaking Persuasively, Essentials of Writing, Projecting a Professional Image

Training courses:

HIPAA Certification First Aid Instructor CPR Certification Instructor Phlebotomist

Medical Assistant EMR Vital signs workshops, Phlebotomy

Certified Billing/Coding Specialist Systems: Aprima Centricity Allscripts NextGen EHR, Practice Centrix Fusion HealthFusion, Meditouch, Medicruz, DETECTS ISET NICE PICTS EPIC, Emdeon Gemstone ECW System, Oxford Medisoft AO FLAG TIPHistorical COSMOS FLAG AFRS 3M DRG RAF, CollaborateMD Theranest QuickBooks, intuit, SQL Coding, Government Billing, TSheets, SharePoint, SailPoint, Compliance 360’, PeopleSoft, Keyed in(payroll) FWA Shield, FEP, NASCO, FACETS, G6, DME Coding, Blue2, Salesforce, Kareo, Dropbox

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