SUMMARY:

Privacy Monitoring | Risk Mitigation | System ImprovementA dedicated and versatile healthcare professional with a 28+ years career in auditing, compliance, and financial services in the healthcare sector. Skilled in leading compliance audits and the monitoring of operational processes, reviewing, and accessing data for compliance. Innovative in implementing compliance plans to optimize efficiency and transparency. Specialized in analyzing regulatory data and information to maintain up to date working knowledge. Exceptional attention to detail and ability to navigate the complex world of HIPAA and health insurance regulations and guidelines.

• Healthcare Informatics
• Federal/State Compliance
• Compliance Audits
• HIPAA Expertise
• Legal & Regulatory Compliance
• Risk Assessment & Management
• Medical Claims & Billing
• CPT/ICD/HCPCS / DRG
• Program Development
• Process Improvements
• Information Security
• Staff Training & Development

TECHNICAL SKILLS:

• Operating System: Microsoft office, Data Management Systems and Information Security Systems.
• Iatric Auditing Software
• Epic Electronic Medical Record Software
• Cerner Electronic Medical Record Software
• Hospital business office operating systems

PROFFESSIONAL EXPERIENCE:

Confidential, Atlanta, GA

Privacy Auditor

Responsibilities:

• Reduced the number of unauthorized employee access to patient medical records by 85% by increasing the number of weekly audits.
• Develop, share, and incorporate organizational best practices into Confidential compliance business applications.
• Initiate investigations and ensure documentation of regulatory deficiencies. Determine the need for corrective action, ensure appropriate documentation and determine effectiveness of the action.
• Analytically review, edit, and develop hospital regulatory compliance policies and procedure, including communicating and implementing changes.
• Collaborate with other departments concerning compliance issues for investigation and resolution.
• Perform as an independent review and evaluation body to ensure compliance issues/concerns are appropriately evaluated, investigated and resolved.
• Conduct outbound calls and electronic communications to internal and external employees reducing risk.
• Principle lead in the identification and analysis of employee/user requirements, procedures, and problem to existing processes concerning compliance.

Privacy Auditing Coordinator/Information Security 

• Accountable for creating and drafting the quarterly compliance audit report and presenting the report to management.
• Assisted in the development, implementation, and revision of policies, procedures and practices to meet regulatory standards and provide guidance to workforce member on preventing illegal, unethical or improper conduct concerning patient’s health information.
• Provided education to departmental managers and employees that was in line with the organization and government policies concerning patient’s privacy.
• Assisted the Manager and Senior Director of privacy and information security in creating and implementing a training plan, Iatric auditing tool, and auditing plan to ensure compliance with regulation to protection of patient health information.
• Reinforced business initiatives through data analysis, identification or implementation barriers and user’s acceptance testing of various systems.
• Resolved compliance issues and identified opportunities for process redesign and improvements.
• Completed detailed analysis on multiple projects, recommended potential compliance resolutions and ensure successful implementation, including revision of the Iatric audit tool.

Recovery Audit Contractor Support Specialist/Compliance

• Identified problem claims, appeals and created appeals letters to Medicare.
• Collected 85% of all money due to Confidential after appeal was reviewed by Medicare.
• Consulted with case management concerning quality assurance.
• Appraised risks and concerns and communicated to management.

Confidential, Stockbridge, GA

Denials/Appeals Management Specialist

• Systematized and reviewed technical/administrative denials for all payer’ and targeted problem areas which affected claims payment.
• Reviewed accounts for documentation od accurate or inaccurate claims adjudication, and documented in Managed Care Database and hospital information system.
• Investigated and researched reason(s) for denials or underpayments on assigned account.
• Performed analysis for revenue cycle insufficiencies to avoid billing and regulatory claims edits, claims denials and other charge capture issues.

Patient Financial Service Representative

• Developed and administered policies and procedures for department specific goals.
• Produced monthly employee incentive program to increase cash collection from $1 million to $3 million per month.
• Maintained the hospital’s credit and collection policies as it pertained to collection and follow - up.
• Implemented a system to track unpaid accounts and claims.
• Maintained and monitored up front collections from $4,000 per day to $20,000 per day.
• Trained staff in utilizing current coding ICD-9 and CPT coding rules, insurance terms (i.e. HMO/PPO, EOB, etc.) and payment methodologies.

Confidential, Decatur, GA

Account Follow-up

• Developed and modified procedures and documents related to revenue cycle policies and procedures.
• Assisted in Implementing a system to track unpaid accounts and claims.
• Presided over claims investigations, reviewed insurance policies, and manage insurance data reports.
• Assisted in employee hiring, evaluations, training, and auditing.
• Managed operations and production of billing, claims, and insurance follow-up.