Medical Coding Specialist (ICD-10/CPT)

SANDRA L YOUNG, Physician Coder

Webster Springs, 26288, 304-***-****, ************@*****.***

SUMMARY Highly motivated RHIT and CCS-P certified professional with over 13 years of experience in medical coding and health information management. Proven ability to accurately assign ICD-10-CM, CPT, and HCPCS codes across various healthcare settings, including Cancer Centers, outpatient, and Critical Access Hospitals. Expertise in Epic and 3M systems, ensuring regulatory compliance and efficient data management. Eager to leverage comprehensive coding skills and commitment to accuracy to support Omega Healthcare Management Services in optimizing medical record documentation and billing processes. WORK EXPERIENCE

Coding Specialist II

WVU Medicine

01/2012 – Present Morgantown

Maintained RHIT and CCS-P certifications.

Instituted secure coding practices to safeguard sensitive patient data from unauthorized access.

Contributed to technical design reviews, proactively identifying potential implementation risks.

Authored comprehensive documentation for coding processes and procedures to support future reference and maintenance. Specialized in Cancer Center coding and all outpatient and Critical Access Hospital coding.

Proficient with 3M and Epic systems.

Skilled in Microsoft Word and Excel.

Possess basic PC and maintenance knowledge.

Experience as a Remote Coder.

Active member of AHIMA.

Utilized ICD-10-CM and CPT coding to accurately complete medical records. Reviewed medical records to assign codes in accordance with established classification systems.

Resolved medical coding edits and billing rejections related to code assignments.

Evaluated clinical documentation to complete diagnosis coding and ensure specificity requirements are met, supporting clinical indicators. Examined medical records for completeness, accuracy, and compliance with all relevant regulations.

Assigned patients to Diagnosis-Related Groups (DRGs) utilizing appropriate computer software.

Director of Medical Records

Webster County Memorial Hospital

03/1990 – 01/2012 Webster Springs

Directed the comprehensive management of patient records, ensuring strict adherence to healthcare regulations and standards. Pioneered efficient record-keeping processes that significantly improved data retrieval and documentation accuracy.

Collaborated with clinical staff to optimize information flow between departments, thereby enhancing patient care delivery. Mentored and trained new team members on established record management protocols to ensure consistent adherence to best practices. Executed regular audits of medical records to identify discrepancies and reinforce data integrity measures.

Formulated policies for the secure handling of sensitive patient information, guaranteeing compliance with confidentiality and privacy regulations. Managed operations within a Critical Access Hospital setting. Maintained RHIT and CCS-P certifications.

Proficient with 3M systems.

Championed initiatives for continuous quality improvement in medical record management across the organization.

Performed systematic audits of medical records files to ensure proper archiving and retention.

Conducted monthly reviews of charts to verify coding accuracy and timely completion by physicians and providers.

Contributed to the development of policies and procedures governing the release of information to external entities, including insurance companies and legal firms.

Successfully organized and maintained medical records, upholding the highest standards of accuracy and confidentiality. Supervised a team of medical record clerks, providing expert guidance on best practices for data entry and document management. Actively participated in various hospital committees to ensure the consistent metting of quality standards.

Audited existing medical records to confirm accuracy, completeness, and compliance with regulatory requirements.

Managed all aspects of a paper-based medical records system, developing and implementing effective filing systems for rapid information retrieval. Prepared detailed statistical reports on departmental activities, including key productivity metrics.

Engaged in the development and implementation of new technologies, including electronic health records and digital imaging systems. Oversaw the full lifecycle of staff management, including recruitment, hiring, orientation, and training, in strict accordance with applicable laws and regulations.

Directed recruitment, hiring, and comprehensive training programs for personnel.

Supervised and evaluated the work activities of medical, nursing, technical, clerical, service, maintenance, and other staff personnel. Administered programs and services within the healthcare and medical facility, encompassing personnel management, training, and coordination of medical, nursing, and physical plant staff.

Consulted with medical, business, and community groups to address service challenges, respond to community needs, foster public relations, coordinate activities and plans, and promote health programs. Analyzed facility activities and data to support strategic planning, cash flow management, risk mitigation, and service utilization optimization. EDUCATION

Fairmont State University

AA, Health Information Management Technology

Fairmont, US

Achieved a GPA of 4.0.

Graduated with Honors.

SKILLS HIPAA compliance Clinical documentation

Claims processing Data entry

Insurance coding (ICD-9 and ICD-10

and CPT)

Coding error resolution

Medical terminology Knowledgeable in EPIC and 3M

Document management Workflow management

Records management Anatomy

Continuing education Performance improvement

Medical record security Documentation oversight

Cancer Center Coding Outpatient Coding

Critical Access Coding Data entry and management

Medical coding and abstracting Error reporting

Ethical standards Teamwork

Multitasking Attention to detail

Problem-solving abilities Organizational skills

Excellent communication Adaptability and flexibility Reliability Self motivation

Professionalism HCPCS

AHIMA Acute Care Coding

Profee Coding

RHIT

CCS-P

CERTIFICATES

REFERENCES,

Contact this candidate