SUMMARY

• Excellent written, software and oral presentation skills from staff to C-Level
• Medicare, Medicaid, heavy regulatory and compliance experience
• In depth knowledge of Project Management in 40101A1, x12 5010, TR3
• In depth knowledge of Project Management in ICD-10, EHR, Eprescribing and Quality analysis, assessment and implementations
• PMBOK knowledge not certified
• Experience in complete Revenue Cycle Management, Access, Coding IP/OP, Coding Audits APC/DRG, Compliance audits, Claims Audits, Appeals, Pre-authorizations, Benefits, Billing, contract management, CDM, cash posting, collections, All payer experience, Clearinghouse, Revenue Cycle Analysis, Payment methodologies
• Clinical, Revenue, Coding and IT, Multi-specialty, Multi-physician, Multi-site, Multi-state, Multi-hospital project experience
• Strategic business planning, process analysis, re-engineering and implementation project experience
• Payer/Provider multiple software, applications, databases, programming, configuration, SDLC, RUP, UAT, training, interfaces and applications, end to end testing
• LPN AAS degree inactive, CTR inactive DeVry University for RHIT
• National Consulting Experience-Owned and operated personal Consulting Firm
• Advocate of motivational management, experienced in transformational and change management with most provider and clinician specialties
• Public Speaking to large audiences for profit and not for profit organizations, foundations and task forces
• RAC and Compliance Audits, Automated pre-editing software creation experience for CMS
• Budget preparation and profitability projections, feasibility studies Financial analysis, cash flow, trends and benchmarking
• Freelance writing, Health policy issues, Coding, Regulatory changes, future trends in healthcare
• ICD9, ICD10 CM/PCS, ICD10 WHO cert 1990 , I-9 to I-10 mapping, software conversions, processes for 40101A and x12 5010, CPT, HCPCS, ICD-0, MeSH certified 1980's, Revenue Codes, BETOS, HCC, SNOMED, HL7, User License LOINC, Modifiers, Pharmacy, DME, Research User License UMLS, SNOMED SNOMED CT , learning HL7/SNOMED Integration, Mentored by workgroup Denmark for SNOMED to I-10 mapping.
• Actively participating in National and State organization task force for Clinical documentation, ICD10 Implementation, E H R, Quality care issues.
• Teaching past experience , Community Colleges, Organizational onsite training in multiple disciplines of healthcare, teaching facilities for coding and reimbursement-business management, HR and other business related tools.
• Extensive experience Medicare and Medicaid Regulations and research, current changes, MMIS, MITA, MCD Enterprise Toolkit, APDs, Medicaid experience in multiple states.

CONFIDENTIAL

• Contract position as CONFIDENTIAL, x12 5010/ICD10. Position was responsible for identification of needed x12 5010 changes and/or level 1 testing and preparation for ICD10 status enterprise wide proving data to prepare and provide feedback to Ernst and Young and 3M prior to their on site assessment. Familiarization with new versions of Epic x12 5010, EHR and ICD 10 work products. Attended Conference calls for Epic users to hear their concerns and the ramifications they were having in x12 5010 testing, EHR, and ICD10 impacts and issues.
• Overviewed and analyzed scheduled software upgrade plans to determine if x12 5010 formatting and testing was required and/or if ICD10 implementation needed to occur or if system would be sunset. Coordinated contract negotiations through appropriate hospital staff for necessary upgrades or x12 5010 testing or locate resources to perform testing. Worked with business office staff to clarify changes that would impact their work flows by impending upgrades and or x12 testing requirements, discuss ramifications, process, documented test plan and system requirements. Documented project on PM software to determine budget, resources, timelines, milestones and
• Recommendations and guidance forming Coordinating Committee for ICD10 project prior to Consultants arrival. Created Charters, business plan, project plans in PM software, budget, flows in Visio showing software, interfaces etc. for different phases of x12 5010 and ICD 10 assessment. Provided assistance in identifying contract negotiations that would be required in obtaining resource staff to start x12 5010 testing. Shared information regarding specific software, created plans, meetings, scripts, timelines and expectations. Gathered relevant ICD 10 data and x12 5010 data to ensure upgrades, testing, retrieving information from software companies, vendors, business associates.
• Analysis of data supplied by organization was used to identify and document plans to initiate calls to Vendors, Payers, Business Associates, Clearinghouse and identify their status for x12 5010 testing and ramifications or questions to ask for ICD 10 implementation, editors, billing and possible denial based on types of vendors if it was a clearinghouse. In the process of identifying where editing processes in Epic system to determine final risks from entire process of billing under x12 5010/ICD 10 to obtaining reimbursement vs denials.

CONFIDENTIAL

• ICD-10 SME for the State of Michigan Medicaid MMIS.
• Actively participated in the NCPDP D.O. version 3 and 40101A/x12 side by side 5010 design and testing with claims and system reviews. The new system changes incorporated over 500 change requests that CMS received over the years. 5010 Team was already organized for Medicaid State. Guides were not available and extensive research, training and planning ensued based on guides provided by multiple organizations. Close relationships with BCBS Association were nurtured leading to better understanding of TR3 background, reports and changes. Rationale and workgroup information was provided for training. Analyzed encounters and detailed system design documents to review with business staff, IT and other HIPAA related staff. Modification of screens and line by line 40101A to x12 5010 comparison along with other transitional work for I-10 conversion activities. Review of all element identifiers, ISA's, verses 40101A Identifiers and transaction set controls, values and notes. Identification of new situational rules or elements, deletions, usage changes in order to modify files to fit compliant testing. Identification of claims, data to perform testing with in order to test each of the changes from the 4010 to 5010 environment. Since the client was Medicaid there were additional modifications that had to be taken into consideration when making modifications to the electronic file. Software modification of all remittances, benefit documents, and other Medicaid related documents were reviewed and recommendation for changes were suggested. Level 1 testing was performed in January 2011.
• PM position drafting strategy document and proposal to the State governance committee to present a extensive gap analysis, assessment, the impacts, risks policies procedures developing a budget and other considerations including our technical migration strategy for the implementation of I-10. Identification of other resources, SME's, Consultants etc.as part of this scope. Technical ramifications were supplied and identified for CNSI regarding software, required changes to the software, rules and editing processes to accommodate x12 5010 and ICD10. Utilized for multiple other projects and proposals relating to automated pre-editing processes for CMS pre-RAC processes, MSDRG evaluations, analysis of claims processing indicators and other compliance/coding related activities for MMIS certification.

CONFIDENTIAL

• Guiding provider systems specifically with their revenue cycle and defining their EMR quality initiatives. Evaluating IT functions, security, data fields in order to pull files and transfer in x12 5010 or tab delimited files to CMS. Monitoring preparation for implementation and data pull for ICD10 conversions when gap analysis and implementation activities begin. Assisting practices with decision making process for electronic file conversions from paper and electronic billing processes. Identifying changes and requirements that will be needed to meet incentive measures.
• Pediatric integrative health organization. This half-time position as Administrative Manager played a key role in establishing the following for the group: the culture leadership team practice infrastructure recruitment functions EMR and other related healthcare technology extraordinary quality and patient safety results patient/employee/physician satisfaction protocols branding/marketing.

CONFIDENTIAL

Sr IT Business Analyst

Responsible for maintenance of code sets all coding files , auditing files, filtering files for editing, analysis and configuration of benefits. Position primarily deals with IT projects, tasks assigned by management in collaboration with the pricing team. Work is done within the Diamond and Facets system for the UHG Americhoice product for eight states. Projects and tasks can include configuration of any part of the benefit, claim hold, coordination of benefits, code sets and other keywords relating to benefit files. Large projects may include default medical definitions, procedure groupings, setting up entire lines of business for benefit packages that can take 30-90 days for implementation. Position requires heavy claims and coding knowledge as well as in depth contract and reimbursement practices, SOX audits, preparing audit packages for finalizing projects RUP, end to end testing, UAT .

CONFIDENTIAL

Reimbursement Operations Supervisor CONFIDENTIAL

• This position was responsible for a high volume contact call center environment consisting of approximately 20-80 direct reports in preparation for a variety of healthcare product support programs with complex escalated reimbursement issues.
• Supervisor was accountable for fiscal and administrative workflow functions applicable to reimbursement support programs for the Western CONFIDENTIAL Our clients consisted of physicians, hospitals, payers and drug manufacturers. This position was accountable for setting and achieving deadlines relevant to the payer requirements. Training with each state CMS and Medicaid business primarily. My position handled the western half of the US.
• While planning the launch of a new FDA approved drug our staff prepared quality simulations in order to prepare them for 'live' calls including training referencing coding methodologies for each type of provider specialty. My staff also had the opportunity to network with other departments assisting with ongoing projects and took the time to mentor each other as well as openly providing constructive dialogue to support each other.

CONFIDENTIAL

Director, CONFIDENTIAL

• After 7 months deadline was 1 year a complete identifiable revenue cycle and working business office was established and performing inpatient/outpatient billing and payment processes. Two clinics were being divested to other PNO's as stated in the original contract with Magellan. Once the transition of the other clinics began moving forward, a lower paying supervisory position was co-trained and I left my position.
• Independently examined and analyzed the clinic performance by site provided development recommendations and assisted in implementing action plans to improve the encounter production, revenue detection, admission and eligibility procedures and identify coordination of benefits. Individual additional coding and encounter training for providers was recommended to executive staff prior to their transition to other PNO's.
• Maintained a close relationship with the Medicaid and County project leaders to monitor encounter production and quality of billing processes. Many lost charges were identified as each clinic was reviewed and processes were put in place prior to their transition to a PNO.
• Coordinated data transfer to REBA for claims payment, monitoring data speeds, testing transfer data for compliance and accuracy, debugging process when necessary.
• Start up process included pulling data base reports to cross check data entry of background coding and editing sequences. Electronic billing testing 40101A HIPAA requirement testing and reviewing EDI data. Monitoring flow of EDI information and working with REBA to resolve any errors whether that was technical information in the ClaimTrak system or relational information.
• Transitional position consisting of overseeing selection, implementation of Claim Trak billing software and staff. Software implementation included charge master for 23 behavioral health clinics and 1 Urgent Psychiatric Center with urgent, crisis, emergency, observation and inpatient services with an average of 500 million/year accounts receivable. Clinics were staffed by 1500 providers and 600 support providers and co-located staff of different disciplines working with consumers to provide services for all behavioral .healthcare, peer support, counseling, housing and case management needs.

CONFIDENTIAL

• Utilizing Medicare, Medicaid, FDA, NIH and CCOG regulations to determine clinical trial Sponsor financial responsibility and assist with contract negotiations I have worked extensively on drug and device clinical trials and responsible for leading client relationships, managing projects and programs, defined project models to ensure financial success during key trials.
• Reviewed current billing and coding processes for claims involving research patient and drug affects, made recommendations to increase hospital revenue and correct coding for claims submission. Modification when necessary to Consent Form, Study designs to share with the IRB committee.
• Performed APC/DRG coding reviews for clients prior to and after interaction with client and making changes to their reimbursement and study system.
• In depth reviews utilizing regulations to ensure compliance and accurate billing/reimbursement for the facility with emphasis on Medicaid and Medicare claims
• Knowledgeable of Good Clinical Practice guidelines, Quality and Core guidelines, Code of Federal Regulations as well as other FDA regulations governing human subject protection, the fundamentals of regulatory affairs, primarily for guidance in medical device and pharmaceutical trials
• Adept at all levels of internet research referencing regulatory, federal, OIG, DOJ, State and County laws.

CONFIDENTIAL

• development and implementation of a new physician and hospital billing service organization.
• Set up all electronic processes related to billing secure PHI to multiple contracted carriers, EDI 40101A testing, HIPAA related, ensuring all documentation was compliant with Private Health Information act.
• Overseeing all healthcare coding and billing processes with approximately 7 on site employees 8 offsite employees Familiar with all payers in the counties of Nevada including Washoe and Clark. Provided written reports to clients and principal regarding their managed care agreements, admitting, financial eligibility, registration, coding and billing processes to ensure compliance with Managed Care, Medicare and Medicaid guidelines. Performed coding audits for hospital clients APC/DRG, CPT ICD, medically necessary for ancillary services from registration points.
• Monitoring data processing for payments and benefits from primary health plans since a large amount of credit balances identified back to charge master coding, IT processing and health plan data.

CONFIDENTIAL

• Oversee and assist coding and consulting staff approximately 20 in their performance of Charge master and rebasing projects, evaluating HIPAA compliance and 40101A testing, cost reporting analyses, managed care and other large reimbursement related projects which included Provider Based designation projects, site specific-coding specific reviews and defense audits, risk assessments, coding compliance audits for APC/DRG reimbursement
• Assistance to prepare for JCAHO
• Required to integrate with executive management of every department of a specific contracted hospital, long term care facility and other healthcare agencies physicians, home health etc internal and external customers.
• Projects could involve coordinating information and meetings with up to 100 a hospital's management staff in order to meet specific contract demands and timelines
• Managed care contract reviews for multiple multi-hospital systems nationwide
• Maintained budgets and project timelines
• Demonstrated a clear understanding of profit and loss management and budget development processes Presented findings and proposals to Hospital Administration and Department Directors utilizing Power Point and other presentation software and materials
• Assigned staff to projects trained them in proper work methods and techniques, conducted performance evaluations, implemented discipline and conflict resolution procedures
• Solely responsible for implementation, marketing and contract negotiations for new product line of Compliance auditing and Risk assessments for all types of healthcare entities, with an average of 74 profitability for each audit
• Compliance investigations utilizing the OIG auditing process and RAT-STATS sampling process Experienced in working with Federal and State Officials, DOJ and OIG to assist with further investigation and disclosure as necessary for improper claims practices
• Maintained knowledge and trained staff in all relevant regulatory changes relating to CMS, state Medicaid processes and county laws
• Familiar with RAC auditing processes.

CONFIDENTIAL

• Compliance and Risk Assessments with cooperation of Horizon Healthcare to overview cost report submission prior to billing.
• Direct supervision of all Physicians, supervisory staff of clinical, billing and coding departments Responsible for maintaining a close working partnership with Horizon CMS Healthcare and all recruited Physicians
• Responsible for construction, interior decorating, staffing, information systems, physician recruitment, accounts payable and receivable systems with Horizon Healthcare, marketing and all managed care contract negotiations acting on behalf of Horizon Healthcare for multiple senior health clinics in the southwestern CONFIDENTIAL U. S. comprising of five multistate, multispecialty clinics
• including Physician staff

CONFIDENTIAL

• Directed by the CFO to assist the Director of Patient Accounts in overseeing the admitting and business office, accountable for budget and staff of approximately 89 employees and 6 managers in a union, county environment. Interactive with IS Department using SMS MS4 , SQL and AS400 programming. Programmed custom reports on the SMS system to assist in analyzing accounts receivable, managed care contract reimbursement and registration issues to develop strategies to decrease their days in AR.
• Under Administration's direction, presented proposal, planned and executed and outpatient billing and coding division of 30 staff within 100 days goal of 120 days which included personnel selection, training, policies, procedures and quality control to expedite the billing of all outpatient claims for the health system.
• Performed charge master and coding/charging review of all outpatient areas supplying recommendations to Administration, assisted in implementation of charging strategies rebasing
• Assisted in establishing electronic eligibility processes with Nevada Medicaid as one of their largest providers in the State of Nevada to be performed two times a week and provide eligibility and correct billing information for
• Worked with Clark County Social Services as the UMC liaison in the formulation and implementation of a database to manage online claims and eligibility for hospital inpatient and outpatient claims in order to expedite payment and eligibility approvals. This required working with County and UMC executive staff to assure guidelines and deadlines were met. As IT liaison with County process other CONFIDENTIAL healthcare entities would be involved in this IT project in order to integrate appropriately with their systems. Responsible for providing hospital wide personnel, resident and physician training in ICD 9 and CPT principles
• Responsible for the direction of a task team to implement the managed care module on MS4 system to monitor contracts, over and under payment information and develop training materials and sessions for staff on the new system
• Managed Medical Records Department -Responsible for compliance auditing and risk assessments in all ancillary departments compliance auditing and DRG review in Medical Records Clinical Auditing with report, benchmarks and action plans to Administration.
• At the request of the Director of Pharmacy and Administration - Assisted with Pharmacy conversion from an autonomous system to hospital SMS Pyxis system, responsibilities to ensure accurate billing and coding on inpatient and outpatient accounts
• Supervised all patient complaints and all clinical audits including those referred from the State Agencies, these were investigated, corrected all of which were presented in summary to administration via Power Point
• Managed Medical Records Department, Monitoring and assisting with all inpatient and outpatient coding, release of information and clerical activities, quality assurance processes particularly for loose filing. Assisted management in teaching staff when necessary and of the need to query physicians etc. Assisted management in preparing and passing JCAHO Accreditation.
• Planned, marketed, set up, and managed over nine 9 Physician Practices cost centers of approximately 20 Physicians and 30 staff including accounts payable, P L, receivables and budgets which integrated with hospital management, information systems, accounts payable, contracts etc.