Arthur R Socia
New York,NY
Summary
Dynamic Health Risk Education Specialist with CVS Health, leveraging expertise in risk adjustment coding and quality assurance to enhance healthcare delivery. Proven track record in provider training and critical thinking, achieving a 95% accuracy rate in coding audits while fostering team collaboration to drive process improvements and elevate patient care standards.
Overview
9
9
years of professional experience
1
1
Certification
Work History
Health Risk Education Specialist
CVS Health
New York, New York
09.2023 - 06.2025
- Responsible for educating providers on how to properly document medical services and interventions during chart reviews including proper coding and claim submission for services rendered.
- Serves as a liaison to peers to provide in-depth clinical knowledge and expertise to support the education of providers.
- Performs audits of medical records to ensure all assigned ICD-10 codes are accurate and supported by written clinical documentation.
- Leads work groups to develop learning strategies to improve health care delivery performance.
- Serves as the training resource and subject matter expert to regionally aligned network practices.
- Identifies and recommends opportunities for process improvements at the practice level to improve overall risk adjustment scores and gaps.
- Simultaneously manages multiple, complex projects.
- Developed training materials for clinical staff on health education programs.
- Collaborated with healthcare teams to implement educational resources effectively.
- Analyzed feedback from training sessions to improve program content and delivery.
Coding Education Specialist
Honest Medical Group
Tampa, Florida
09.2022 - 09.2023
- Developed educational programs for patient engagement and health literacy.
- Designed assessment tools to evaluate learning outcomes and program effectiveness.
- Collaborated with healthcare professionals to integrate education into patient care plans.
- Coordinated training sessions for staff on effective teaching techniques.
QA Specialist
Apixio
09.2021 - 09.2022
- As a recognized expert in medical coding regulations, guidelines, updates, and industry best practices, I played a pivotal role in ensuring unwavering quality assurance for individual encounters.
- I employed established coding conventions, guidelines, and regulations to conduct meticulous evaluations of coded data, leaving no room for error.
- Furthermore, I diligently reviewed and evaluated coder-submitted rebuttals, collaborating closely with Coding Leadership to conduct in-depth root cause analysis of coding quality issues.
- This includes conducting comprehensive account reviews and actively contributing to the development of coding quality action plans.
- Upholding the utmost standards of coding accuracy and documentation integrity, I diligently reviewed coding opportunities assigned by the Coding Manager.
- Through these assignments, I meticulously validated the appropriateness of documentation and coding for submitted work items.
- Additionally, I consistently provided reliable backup support for Hierarchical Condition Category (HCC) coding, maintaining an exceptional accuracy rate of 95% or higher.
- Throughout these endeavors, I consistently surpassed productivity and accuracy benchmarks set by the Coding Director/Manager.
Risk Adjustment Coder - Auditor
Agilon Health
11.2021 - 06.2022
- Meticulously audited retro encounters to ensure comprehensive and well-supported documentation of HCC diagnoses.
- Identified missed or newly documented opportunities for improvement.
- Conducted thorough coding audits to assess coding accuracy, documentation completeness, and adherence to risk adjustment guidelines.
- Effectively communicated coding discrepancies to coding professionals, offering targeted education and feedback to enhance coding accuracy and compliance.
- Collaborated closely with interdisciplinary teams to implement corrective actions, improve coding practices, and maximize reimbursement opportunities.
- Evaluated medical records to ensure high-quality documentation, precise coding, and comprehensive risk adjustment coding.
- Maintained unwavering compliance with coding guidelines, regulations, and risk adjustment methodologies throughout the Initial Validation Audit (IVA).
Provider Education - Risk Adjustment Coder - Auditor
Ultimate Health Plans
04.2021 - 09.2021
- Generated monthly Gap and RAF Score reports for the Insurance Plan IPA's, offering valuable insights into areas of improvement.
- I actively contributed to provider education initiatives by creating informative documents and engaging PowerPoint slides for monthly discussions.
- In addition, I conducted retrospective audits of assigned IPAs to ensure accurate reporting and documentation of Hierarchical Condition Categories (HCCs).
- During the Covid-19 pandemic, I performed Telehealth audits to verify proper documentation of encounters, including both audio and video components, while ensuring accurate capture of HCCs.
Risk Adjustment Coder
Diagnostic Clinic Medical Group
12.2020 - 04.2021
- Assigned accurate diagnosis codes, including HCCs, to capture and document patients' health conditions for risk adjustment purposes.
- Conducted comprehensive reviews of medical records to ensure accurate and complete documentation supporting risk adjustment coding.
- Collaborated with healthcare providers and coding professionals to address coding queries, clarify documentation, and improve coding accuracy.
- Maintained compliance with coding guidelines, regulations, and risk adjustment methodologies.
- Participated in coding audits and quality assurance activities to assess coding accuracy, identify areas for improvement, and implement corrective actions.
Risk Adjustment Coder
UnitedHealth Group
04.2019 - 12.2020
- Accurately assigned diagnosis codes, specifically HCCs, to capture and document patients' health conditions within the UnitedHealth risk adjustment system.
- Conducted comprehensive reviews of medical records to ensure accurate and complete documentation supporting HCC coding.
- Collaborated with healthcare providers and coding professionals to address coding queries, clarify documentation, and improve coding accuracy.
- Maintained compliance with UnitedHealth coding guidelines, CMS regulations, and other coding standards.
- Played an instrumental role in coding audits and quality assurance initiatives, conducting meticulous evaluations of coding accuracy.
- Demonstrated a strong commitment to identifying opportunities for enhancement and implementing targeted corrective measures in a proactive manner.
Hospice and Home Health Medical Coder
Suncoast Hospice
08.2018 - 04.2019
- Accurately assigned ICD-10-CM diagnosis codes and HCPCS/CPT procedure codes for hospice and home health care encounters.
- Conducted thorough reviews of medical records to ensure documentation supports coding and captures necessary details for accurate billing.
- Collaborated with interdisciplinary teams to obtain missing or clarifying documentation, address coding-related queries, and enhance coding accuracy.
- Maintained compliance with coding guidelines, regulations, and reimbursement requirements specific to hospice and home health care.
Risk Adjustment Coder and HEDIS Reviewer
Conviva Care Solutions
10.2016 - 08.2018
- Assigned accurate diagnosis codes for risk adjustment purposes, ensuring appropriate reimbursement and risk scoring.
- Conducted comprehensive reviews of medical records to validate coding accuracy, completeness, and compliance with coding guidelines and regulations.
- Collaborated with physicians and other healthcare providers to clarify documentation, resolve coding discrepancies, and improve coding practices.
- Performed HEDIS reviews, ensuring data collection and reporting adherence to HEDIS technical specifications.
- Identified and reported gaps in quality performance measures and collaborated with teams to implement quality improvement initiatives.
- Participated in coding audits and provided coding education and feedback to coding professionals to enhance accuracy and compliance.
Education
BA Health Information - Health Information Technology
Tampa Institute of Technology
Tampa, FLMedical Billing and Coding Certification -
Erwin Technical College
Tampa, FLSkills
- Health education
- Risk adjustment coding
- Medical auditing
- Provider training
- ICD-10 compliance
- Quality assurance
- Data analysis
- Medical documentation
- Coding regulations
- Clarity in communication
- Critical thinking
- Team collaboration
- Project management
- Attention to detail
Certification
- CPC
- CRC
Personal Information
Title: Senior Clinical Documentation Integrity (CDI) Specialist
Timeline
Health Risk Education Specialist
CVS Health
09.2023 - 06.2025
Coding Education Specialist
Honest Medical Group
09.2022 - 09.2023
Risk Adjustment Coder - Auditor
Agilon Health
11.2021 - 06.2022
QA Specialist
Apixio
09.2021 - 09.2022
Provider Education - Risk Adjustment Coder - Auditor
Ultimate Health Plans
04.2021 - 09.2021
Risk Adjustment Coder
Diagnostic Clinic Medical Group
12.2020 - 04.2021
Risk Adjustment Coder
UnitedHealth Group
04.2019 - 12.2020
Hospice and Home Health Medical Coder
Suncoast Hospice
08.2018 - 04.2019
Risk Adjustment Coder and HEDIS Reviewer
Conviva Care Solutions
10.2016 - 08.2018
BA Health Information - Health Information Technology
Tampa Institute of Technology
Medical Billing and Coding Certification -
Erwin Technical College