Detail-oriented and dependable professional with a proven track record in managing multiple priorities while maintaining a positive attitude. Strong willingness to embrace additional responsibilities to achieve team objectives. Equipped with exceptional problem-solving abilities, leadership skills, and extensive experience in complex outpatient and inpatient coding. Seeking to leverage expertise in a challenging role as a Coding Supervisor to drive excellence and enhance team performance.
Overview
14
14
years of professional experience
2
2
Certification
Work History
HIM Coding Supervisor
Huntsville Health System
11.2023 - 12.2024
Manages the Coding Section of the Health Information Department in collaboration with the Director of Medical Records.
Manages coding staff to include Coders and Coding section support staff consisting of Medical Record Techs and Charge Capture Specialists.
Codes with appropriate ICD-10-CM/ICD-10-PCS and/or CPT codes, abstracts records and prepares statistical reports, assists CDI with physician Queries, assesses workload of coders on a daily basis, establishes priorities for the Coding Section, coordinates work assignments and ensures duties within the Coding Section are covered on a daily basis, provides cross-training and assistance as required, coordinates training for coding employees, monitors and audits the work of the staff assigned to the Coding Section.
Responds to questions from staff regarding current policies, procedures, and regulations, assists with payer denials and appeals, assumes initiative and follows through on any problems concerning the Coding Section, adheres to hospital and departmental policies and procedures, maintains security of confidential information, maintains competence in use of equipment within the department and programs utilized, pursues personal development goals (continued education, reading of coding articles, certificates).
Maintains a professional appearance and attitude, provides support of other departmental functions as needed, performs other duties as assigned by the Director of the department, participates in orientation, training, and management of assigned personnel, supports and participates in the organizational Performance Improvement Activities.
Works with HIM Director to create policies and procedures for coders and coding support team.
Compiles, analyzes and presents data related to coder performance, documentation issues, and charging errors.
Provides ongoing feedback to coding staff on areas for improvement.
Provides daily supervision of coding staff and provides feedback to the Coding Manager on exceptional and/or substandard performance.
Ensures that all members of the coding team are following official policies and standard procedures and conducts discipline for those in violation.
Performs yearly coder performance evaluations.
Counsels coding staff on actions required to meet minimum performance requirements.
Provides quarterly audit and education sessions on different coding topics that the supervisor feels needs to be addressed and at times sends individual education resources to coders needing additional help on specific topics. Gives Director coder audit findings.
Accomplishments while at Athens Limestone Hospital
Created a coding auditing program
Created a coder education program
Created a way for Athens to do away with contract coding to save money.
Created new policies for how coders do their daily worklists
Created new policies for Failed Medical Necessity Hold List daily worklist
MRT CDIS-Outpatient
U.S. Department of Veteran’s Affairs
03.2023 - 10.2023
Responsible for reviewing the overall quality and completeness of clinical documentation. Focusing on improving clinical staff documentation of outpatient encounters through retrospective, ideally prior to coding and billing, review of outpatient encounters and extensive provider education.
Applied comprehensive knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures as well as the principles and practices of health services and the organizational structure to ensure proper code selection.
Reviewed clinical documentation and provided education to clinical staff on outpatient episodes of care for clinic visits.
Prepared and conducted provider education on documentation processes in the health record to include the impact of documentation on coding, workload, quality measures, reimbursement, and funding.
Provided education to providers on the need for accurate and complete documentation in the health record, appropriate code selection of Evaluation and Management (E/M), Current Procedural Terminology (CPT) and ICD-10 diagnosis codes, and ensuring documentation supports the codes selected to the highest degree of specificity.
Adhered to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or evaluation and management (E/M) code to ensure ethical, accurate, and complete coding.
Reviewed VERA input on missed opportunities in provider documentation identified by the VERA coordinator and coordinated provider documentation education with the VERA coordinator. Ensured documentation supports codes based on guidelines specific to certain diagnoses, procedures, and other criteria used to classify patients under the Veterans Equitable Resource Allocation (VERA) program that categorizes all VA patients into specific classes representing their clinical conditions and resource needs.
Monitored ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC.
Assisted facility staff with documentation requirements to completely and accurately reflect the patient care provided; provided technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing. Ensured provider documentation is complete and supports the diagnoses and procedures coded. Directly consulted with the professional staff for clarification of conflicting or ambiguous clinical data. Reported incorrect documentation or codes in the electronic patient health record.
Expertly searched the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient record. Queried the medical staff and other clinical caregivers as necessary to obtain accurate and complete documentation.
Used a variety of computer applications in day-to-day activities and duties, such as Outlook, Excel, Word, and Access; competent in use of the health record applications (VistA and CPRS) as well as the encoder product suite.
Improved overall quality, completeness and accuracy of health record documentation as well as promoting appropriate clinical documentation through extensive interaction with physicians, other patient caregivers and HIM coding staff to ensure clinical documentation and services rendered to patients is complete and accurate.
Ensured the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes with continuing education to all members of the patient care team on an ongoing basis. Identifies trends and/or opportunities to improve clinical documentation.
Collaboratively worked with the professional clinical staff and provided support and education on documentation issues. Assisted in the development of guidelines for data compatibility, consistency, and monitoring for compliance to improve the quality for clinical, financial, and administrative data to ensure that all information is fully documented and supported.
Provided advice and guidance in relation to issues such as documentation requirements, liability issues, advance directives, informed consent, patient privacy and confidentiality, state reporting, etc.
Analyzed situations or processes and recommended improvements or changes in documentation as deemed necessary.
Reviewed the health record and discusses the case with the clinical staff. Performed chart reviews for specific patient populations to facilitate appropriate clinical documentation and ensured the level of services and acuity of care are accurately reflected in the health record.
Tracked the results of audits to identify patterns and variations in coding practices with regular reports to the medical staff and management.
MRT (IP& OP) Coder
U.S. Department of Veteran’s Affairs
10.2022 - 03.2023
Applied knowledge of medical record content, medical terminology, anatomy & physiology, diseases processes, and official coding guidelines to assign codes to the most basic and routine outpatient and inpatient services.
Selected and assigned codes from the current versions of the International Classification of Diseases (ICD) Clinical Modification (CM) and Procedure Coding System (PCS) for inpatient facility MS-DRG coding, and Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS) for inpatient professional coding and outpatient coding.
Selected diagnosis, operation, or procedure codes based on the accepted coding practices, guidelines, conventions, and policy of the VA.
Reviewed record documentation to abstract all required medical, surgical, ancillary, demographic, social, and administrative data with guidance and instruction from supervisor or senior coder to develop knowledge of the organization and structure of an electronic patient record.
Utilized the facility computer system and software applications to code, abstract, record, and transmit data to the national VA database in Austin. Identified data errors are reviewed with a senior coder or the supervisor and corrections made as directed.
Used a variety of computer applications in day-to-day activities and duties, such as Outlook, Excel, Word, and Access; developed use of the health record applications (VistA and CPRS) as well as the encoder product suite.
MRT (IP& OP) Coder
U.S. Department of Veteran’s Affairs
09.2021 - 10.2022
Applied knowledge of medical record content, medical terminology, anatomy & physiology, diseases processes, and official coding guidelines to assign codes to the most basic and routine outpatient and inpatient services.
Selected and assigned codes from the current versions of the International Classification of Diseases (ICD) Clinical Modification (CM) and Procedure Coding System (PCS) for inpatient facility MS-DRG coding, and Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS) for inpatient professional coding and outpatient coding.
Selected diagnosis, operation, or procedure codes based on the accepted coding practices, guidelines, conventions, and policy of the VA.
Reviewed record documentation to abstract all required medical, surgical, ancillary, demographic, social, and administrative data with guidance and instruction from supervisor or senior coder to develop knowledge of the organization and structure of an electronic patient record.
Utilized the facility computer system and software applications to code, abstract, record, and transmit data to the national VA database in Austin. Identified data errors are reviewed with a senior coder or the supervisor and corrections made as directed.
Used a variety of computer applications in day-to-day activities and duties, such as Outlook, Excel, Word, and Access; developed use of the health record applications (VistA and CPRS) as well as the encoder product suite.
Inpatient DRG Coder (remote)
Mobile Infirmary Hospital
10.2020 - 04.2021
Assign principal diagnosis and principal procedure codes.
Assign POA and disposition.
Evaluated impact on DRG from code selection and CDI review.
Queried physicians.
Maintained required accuracy rate of 95%.
OP Coder (remote)
Baptist Memorial Healthcare
03.2020 - 10.2020
Assign diagnostic and procedure codes to Oncology office visits/infusion charts.
Work Claim edits daily (NCCI edits).
Work Follow up/denials.
Enter injection and infusion charges on front end.
Assign deficiencies to physicians for incomplete charts/attestations.
Contact hospital pharmacy for drug denials.
Certified Coding Specialist III (remote)
Cape Fear Valley Health Hospital
04.2018 - 03.2020
Assign diagnostic and procedure codes to observation and surgical cases.
Work edits for medical necessity.
Attend monthly meetings with HIM staff.
OP Coder (remote)
Baptist Memorial Healthcare Hospital
04.2016 - 03.2018
Assign diagnostic and procedure codes to OP charts.
Worked the medical necessity edits daily.
Code charts under the ICD-10-DM and CPT.
IP/OP Coder (remote)
Himagine Solutions
12.2015 - 03.2016
Company Overview: (Children’s of Alabama contract coder)
Assign diagnostic and procedure codes to IP/OP charts.
Worked the medical necessity and CCI edits daily.
Code charts under the ICD-10-DM and DRG assignments.
To abstract required data into hospital abstracting system to determine the hospital database and reimbursement of hospital claims.
Follow JACHO standards.
(Children’s of Alabama contract coder)
IP Coder (Orthopedic charts) (remote)
Precyse Solutions
09.2015 - 12.2015
Assign diagnostic and procedure codes to Inpatient (Orthopedic charts).
Worked the medical necessity and CCI edits daily.
Code charts under the ICD-10-DM and DRG assignments.
To abstract required data into hospital abstracting system to determine the hospital database and reimbursement of hospital claims.
Coder III (remote) (IP and OP)
Children’s Hospital of Alabama
04.2015 - 09.2015
Assign diagnostic and procedure codes to Inpatient and Outpatient (Ancillary, ER, Surgery, and Observation, Injection and Infusion Coding).
Worked the medical necessity and CCI edits daily.
Code charts under the ICD-9-DM and HCPCS System.
To abstract required data into hospital abstracting system to determine the hospital database and reimbursement of hospital claims.
Follow JACHO standards.
Certified Coding Specialist II (remote and on-site)
Baptist Health Systems
03.2012 - 09.2014
Assign diagnostic and procedure codes to Outpatient and Inpatient (Ancillary, ER, Surgery, and Observation, Injection, and Infusion Coding).
Worked the medical necessity and CCI edits daily.
Code charts under the ICD-9-DM and HCPCS System.
To abstract required data into hospital abstracting system to determine the hospital database and reimbursement of hospital claims.
Follow JACHO standards.
Certified Outpatient Coding Specialist I (remote and on-site)
Gadsden Regional Medical Center
02.2011 - 03.2012
Assign diagnostic and procedure codes to Outpatient Diagnostics, OP Surgery and Emergency Room medical records.
Code charts under the ICD-9-DM and HCPCS System.
To abstract required data into hospital abstracting system to determine the hospital database and reimbursement of hospital claims.
Follow JACHO standards.
Education
Associate degree - Health Information Technology
Wallace State Community College
Hanceville, Alabama
08.2010
Skills
EPIC system software
Legacy
3M 360/CAC
VISTA
Cerner
HDM
CPRS
Certification
Registered Health Information Technician (RHIT), 2011-01-01, 2025-12-31