Medical Quality Assurance

RUSTY HEFNER CPC, CPC-H

** ******** *****,  Acworth Ga 30101

770-***-****

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

CERTIFIED PROFESSIONAL MEDICAL CODER

Certified Professional Coder (CPC / CPC-H) with a proven track record in Medical Coding, Electronic Medical Records, Medical Policy, Insurance Support, and Coding Consulting Services. Over a decade of Medical field experience, including Emergency Department Medical Coding (Physician Services), Medical Policy Advisement, ICD-9 Coding, Chart Audit and Review, and Consulting Services. Known for dedication to quality, dependability, timeliness, accuracy, and professionalism. Skills include:

— EmStat Physdoc Electronic Physician Notes System

— EmStat Emergency Online Medical Record System

— McKesson HBOC Electronic Medical Record System

— Eclipsys “Quest” Electronic Medical Records System — 3M Encoder Medical Coding Systems

— KBT Electronic Medical Transcription System

— Microsoft Excel (certified)

— Microsoft Access (certified)

— CSI Claims Analysis Tool

— WI Adjudication Projection tool set

— Oracle Database Access

— Omega Online Billing inquiry Systems

— Microsoft Outlook

— Formal RVU AMA Training

— Oracle-based Coding Logic System

— Various In-House Coding Logic Tools

Education

Certified Medical Coder (CPC), 2005-Present

Certified Medical Coder (CPC-H), 2007-Present

Certified in Microsoft Excel, 2006-Present

Certified in Microsoft Access, 2005-Present

Chattahoochee Technical Institute, 1996-1998 Respiratory Therapy Curriculums

High School Diploma, 1974 – Jefferson Area High School — Jefferson, Oh

Professional Experience

2007–Present Peachtree Medical Resources Atlanta, Ga

Medical Coder

Responsibilities Include:

 Coding of Emergency Department medical charts for Physician professional services, ICD-9, and facilities fees.

 Responsible for monitoring and reviewing Physician op notes for accuracy and plenitude.

 Responsible for monitoring and managing medical chart reporting to 3rd party billing organization.

 

2008–2010 iHealth Technologies, Inc. Atlanta , Ga

Medical Policy Supervisor

Responsibilities Include:

 Responsible for leading a team of 6-12 Medical Policy business analysts, supporting assigned large insurance payers, advising medical coding and medical policy management. Clients include:

 WellCare

 Wellmark

 Blue Shield (California)

 Wellpoint

 Blue Card Network of Michigan

 Team responsibilities include the monitoring, analysis and response to client inquiries as they relate to claims adjudication.

 Responsible for team work flow management, client assignments, and monthly evaluation of team business analysts, including established monthly metrics and adherence to monthly production and reporting deadlines.

 Responsible for the maintenance of client-specific custom coding logic, including monthly update to baseline and custom coding sets.

 Responsible for ad-hoc analysis of “theoretical” coding scenarios as presented by established clients.

 Responsible for trouble-shooting and maintenance of CPT, HCPCS and ICD-9 coding logic sets, both base-line and custom, based on LCD, CMS and/or AMA policies.

 Responsible for adherence to established Quality Assurance measures. (My team has also been instrumental in establishing “Best Practice” Quality control procedures)

 Responsible for participation in key strategic corporate initiatives, including participation in committees tasked with the design and implementation of in-house tools designed to improve efficiency.

 Responsible for participation in monthly client one-on-one coding logic meetings, providing medical coding and medical policy consultation services in relation to clients provider contracts and pay claims analysis.

 Responsible for the monitoring, evaluating, advising, and mentoring of all assigned staff members.

 Responsible for the following team reporting functions:

 Monthly Production Control Monitoring

 Quarterly Medicare Physician Fee Schedule Updates

 Annual HCPCS Code Changes

 Annual CPC Code Changes

 Trend Analysis

 Responsible for maintaining client-specific medical coding logic database, and writing SQL and Access-based queries for trend analysis reporting.

2005–2008 iHealth Technologies, Inc. Atlanta , Ga

Medical Coder / Business Analyst

Responsibilities Include:

 Responsible for the support of assigned business accounts, providing medical coding services and claims adjudication analysis.

 Clients have included:

 Keystone Healthcare

 AmeriHealth of Pennsylvania

 Blue Shield (California)

 Responsible for the coding logic design, implementation and “go-live” for new client Blue Shield of California.

 Responsible for attending monthly client meetings, providing medical coding advice and support, in conjunction with iHT Medical Director (physician).

 Responsible for the analysis, design, and maintenance of client-specific custom coding logic, as it is applied to client’s pay claims.

 Responsible for Production Control monitoring of daily claims files, as they pertain to claims adjudication.

 Responsible for processing client coding inquiries and claims adjudication inquiries, with response to client within 48 hours.

 Responsible for participation on client support teams, meeting weekly to review and analyze coding logic updates. Client support team duties include claims adjudication issues, minimizing the need for manual claims adjustment intervention, and implementation of AMA and CMS industry updates (quarterly and/or yearly).

 Participation in in-house quarterly Medicare Physician Fee Schedule team, implementing fee schedule updates to all client custom logic sets.

2001–2005 Piedmont Hospital Atlanta, Ga

Emergency Services Data Analyst and Medical Coder

(1st Coding License [CPC] earned while in Employ)

Responsibilities Included:

 Responsible for monitoring Emergency Room charts for accuracy and plenitude.

 Responsible for maintaining Emergency Department Electronic Medical Records system.

 Responsible for entering facility charges related to Emergency Room, Endoscopy Lab, Hospital ER Observation, and outpatient Infusion Lab.

 Responsible for maintaining Emergency Department APC database.

 Responsible for monitoring and maintaining Emergency Department Charge master.

2001-2003 (part time) Coderite St. Louis, Mo

Outpatient Medical Coder

Responsibilities Included:

 Abstracting and Coding of ER outpatient charts for ICD-9-CM Diagnostic and CPT procedural codes.

 Reviewing Physician dictations to determine billable procedures and establish appropriate diagnosis (ICD-9) codes.

 Responsible for AMA CPC coding of Physician Evaluation and Management related services.

 Responsible for CMS ICD-9 coding for ER and clinical setting patients.

 Trained in the use of 3M EnCoder

 Instrumental in the creation of numerous reporting vehicles for performance tracking.

 

My Former Life

1999-2001 Med Commerce New York, Ny

Documentation and Training Manager

1992-1999 American Software Atlanta, Ga

Senior Technical Writer/Documentation Project Leader

1989-1992 Prentice Hall/Simon and Shuster Atlanta, Ga

Senior Technical Writer

1985-1989 Chromatics Atlanta, Ga

Senior Technical Writer/Documentation Project Leader

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