Davina Grant
Macon,GEORGIA
Summary
Experienced Auditor focused on improving business compliance, workflow and processes through detailed audits and optimization recommendations. Successful track record of fully evaluating information, structures and procedures and initiating corrective actions. Advanced skills in different Medical Record Software. Detail-oriented Auditor with track record of quickly completing complex audit projects. Experienced in public and private accounting, specializing in financial statement audits. Well-versed in managing entire audit process from planning and risk assessment to fieldwork. Seasoned auditing professional knowledgeable about risk aversion strategies, cost reduction options and financial processes. Decisive and persuasive communicator with proven problem-solving, leadership and planning abilities.
Overview
10
10
years of professional experience
Work History
Clinical Documentation Specialist
VillageMD
01.2023 - Current
- Review outpatient medical record information on both retroactive and prospective basis to identify, assess, monitor and document claims and encounter coding information as it pertains to risk adjustment and quality metrics
- Ensure that diagnosis codes for each chronic or major medical condition have been captured and submitted within permitted timeframe
- Conducts physician chart audits to identify incorrect coding, prepares reports of findings and any compliance issues. Audits performed for both provider coding accuracy and documentation support as well as coding teammate accuracy
- Reports coding patterns identified within audit process to Manager, and identifies corrective measures to compliance problems
- Maintaining current knowledge of coding guidelines and relevant federal regulations through use of current CPT-4, HCPCS II, and ICD-10 materials, Federal Register, and other pertinent materials
- Assess adequacy of documentation of claims and query outpatient provider claims to obtain additional medical record documentation or to clarify documentation to ensure accurate and appropriate coding
- Interacts with coding teammates to deliver coding audit findings, discuss corrective measures and any necessary training required, and reports findings back to Coding Manager
- Performs related work and projects as required
- Managed electronic clinical documentation and uploaded changes or updates using Athena/EPIC
Risk Adjustment Validation Auditor
Reveleer
10.2023 - 03.2024
- Reviewed outpatient records and interpreted documentation to identify all diagnoses and procedures.
- Abstracts clinical information from variety of medical records and assigns appropriate ICD 10 CM and/or CPT codes to patient records according to established procedures
- Ensure codes are accurate and sequenced correctly in accordance with government and insurance regulations
- Follow up with provider on any documentation that is insufficient or unclear
- Communicate with other clinical staff regarding documentation
- Search for information in cases where coding is complex or unusual
- Receive and review patient charts and documents for accuracy
- Review previous day's batch of patient notes for evaluation and coding
- Ensure that all codes are current and active
Risk Adjustment Coder
Cavo
05.2022 - 09.2022
- Perform member and provider interviews, and review medical documentation as needed
- Gather and analyze data and information gathered to determine behavior and understand provider/scheme at issue
- Utilize appropriate documentation and tracking controls in case tracking system to ensure compliance and audit ability requirements are met
- Apply knowledge of coding guidelines to determine validity of aberrances
- Gather all relevant facts to articulate behavior through Investigation Summary and compliance package. Communicate clear rationale for investigation processes and outcomes to Client, Regulator and stakeholders
- Collaborate with variety of external sources to identify current and emerging patterns and schemes related for FWA to ensure additional TIP submission
- Coordinates research and responds to system inquiries and appeals.
Risk Adjustment Coder
Advantmed
10.2019 - 04.2021
- Reviewing and following up payment denials, contacting insurance carriers for payment resolution, filing appeals, submitting insurance claims to clearing house or individual insurance companies, retracting claims, and processing write offs/adjustments for non-payable charges according to payer contract.
- Analyzes and interprets medical record in its entirety to ensure accurate, complete and consistent selection of diagnoses and procedures to assure production of quality healthcare data and accurate facility payment.
- Applies understanding of basic anatomy and physiology to interpret clinical documentation and identify applicable codes.
- Utilizes resources and reference materials (e.g., on-line sources, manuals) to identify appropriate codes and reference code applicability, rules and guidelines.
- Enter information necessary for insurance claims such as patient, insurance ID, diagnosis, treatment codes, modifiers, and provider information. Ensure claim information is complete and accurate.
- Prepare appeal letters to insurance carrier when not in agreement with claim denial. Collect necessary information to accompany appeal
- Check insurance payments for accuracy and compliance with contract discount.
- Reviewed medical records for completeness and filed records in alphabetic and numeric order.
- Followed exact procedures for handling transfers and other releases of medical records.
Medical Coding and Billing Specialist
Jewvon's Medical Consulting
01.2017 - 04.2021
- Processed insurance company denials by auditing patient files, researching procedures, and diagnostic codes to determine proper reimbursement.
- Attained up-to-date knowledge of coding requirements through continuing education courses and certification renewal.
- Reviewed patient charts to better understand health histories, diagnoses, and treatments.
- Utilized active listening, interpersonal, and telephone etiquette skills when communicating with others.
- Identified control gaps in processes, procedures and systems through in-depth research and assessment and suggested methods for improvement.
- Assessed internal control risks of network through information system audits.
- Communicated with auditing staff to obtain necessary information for audits.
Medical Coding Specialist
Atlantic Lung Center
Macon, GA
01.2014 - 01.2018
- Worked with individual patients to code medical observations and professional services.
- Correctly coded and billed medical claims for various hospital and nursing facilities.
- Verified signatures and checked medical charts for accuracy and completion.
- Utilized active listening, interpersonal, and telephone etiquette skills when communicating with others.
Education
Medical Coding
American Academy of Professional Coders
AAPCEmory Clinic - Certification of Electronic – Medical Billing, Healthcare
Emory Healthcare
Atlanta, GAHigh School Diploma -
Eastside High School, The Galatians Group, Inc
Gainesville, College Park, FL, GA4.2000
Skills
- Knowledge of Risk Adjustment and Hierarchical Condition Categories (HCC) and Medicare Advantage reimbursement
- Task-oriented and ability to meet designated deadlines and productivity standards
- Excellent understanding of medical terminology, disease process and anatomy and physiology
- Excellent understanding of ICD-10-CM coding classification
- Excellent understanding of CPT/HCPCS coding
- Medicaid, Medicare and Commercial business products knowledge/experience
- Proficiency in Microsoft Word, Excel and SharePoint
- Knowledge of CMS-1500 – Health Insurance Claim Form
- Knowledge of federal and state guidelines on all coding systems and sponsored programs
- Advanced knowledge of auditing concepts and principles
- Ability to use independent judgment and to manage and impart confidential information
- Strong oral and written communication skills Excellent organization and problem-solving skills
Timeline
Risk Adjustment Validation Auditor
Reveleer
10.2023 - 03.2024
Clinical Documentation Specialist
VillageMD
01.2023 - Current
Risk Adjustment Coder
Cavo
05.2022 - 09.2022
Risk Adjustment Coder
Advantmed
10.2019 - 04.2021
Medical Coding and Billing Specialist
Jewvon's Medical Consulting
01.2017 - 04.2021
Medical Coding Specialist
Atlantic Lung Center
01.2014 - 01.2018
Medical Coding
American Academy of Professional Coders
Emory Clinic - Certification of Electronic – Medical Billing, Healthcare
Emory Healthcare
High School Diploma -
Eastside High School, The Galatians Group, Inc