HECTOR MORALES
Clermont,FL
Summary
Knowledgeable Medicare Risk Adjustment Manager and coder with a wide experience in reviewing health records to identify proper diagnosis for HCC and HEDIS quality measures. Offers background in reviewing, analyzing and managing medical record information to obtain and ensure the highest reimbursement payment. Detail-oriented team player with strong organizational skills. Ability to handle multiple projects simultaneously with a high degree of accuracy.
Overview
15
15
years of professional experience
Work History
Manager of Medical Coding
Centerwell Primary Care
06.2015 - Current
- Applied official coding conventions and rules from American Medical Association and Centers for Medicare and Medicaid Services to assign diagnostic codes.
- Accurately reporting ICD10-CM diagnostics codes, including secondary diagnosis to the highest level of specificity.
- Maintaining accurate and complete medical record documentation (ICD10-CM codes submitted must be justified with the proper documentation).
- Alerting providers to any erroneous information that has been submitted and following the procedures correcting the data (Validation process)
- Resourcefully used various coding books, procedure manuals, and on-line encoders.
- Reviewed outpatient records and interpreted documentation to identify diagnoses and procedures.
- Interacted with physicians and other healthcare staff to resolve questions about the coding process.
- Reviewed patient charts to better understand health histories, diagnoses, and treatments.
- Verified signatures and checked medical charts for accuracy and completion.
- Utilized electronic medical record systems to store, retrieve and process patient data.
- Followed up with medical staff regarding missing information in patient records.
- Assisted in training new staff on Coding and MRA process.
- Researched and resolved medical record discrepancies.
- Communicated with insurance companies to research and resolved coding discrepancies.
- Reviewed, analyzed, and managed coding of diagnostic and treatment procedures contained in outpatient medical records.
Medicare Risk Adjustment Coder
Family Physicians Group - Centerwell Primary Care
05.2008 - Current
- Ensure the HCC coding matches the clinical documentation to improve the RAF score accuracy
- Educate healthcare providers about MRA documentation and coding guidelines.
- Ensure that all chronic diseases and conditions (risk-adjusted diagnoses) are documented at least once a year.
- Read all reports — lab, hospital, consultation, pathology, biopsy, imaging, etc— to find new risk-adjusted diagnoses and querying about potential new diagnoses.
- Reviews and analyzes clinical documentation to connect with the Appropriate HEDIS measures and identify opportunities for improvement. Also, monitor the success of the quality improvement initiatives (HEDIS), track improvement and provide a set of measurement standards that allow comparison with other plans
- Use MEAT (Monitoring, Evaluating, Addressing/Assessing, Treatment) to ensure that the documentation supports every applicable risk-adjusted diagnosis for validation purposes.
- Guarantee that the medical record is not conflicting, lacking specificity, incomplete, or ambiguous.
- Ensure that the status of chronic conditions, clinical indicators, and management plans are noted in the documentation for support.
- Ensure that each date of service documentation stands by itself.
Clinical Case Manager
Family Physicians Group
05.2008 - 06.2009
- Coordinated services with other agencies, community-based organizations, and healthcare professionals to provide useful benefits to clients.
- Identified care needs of individual patients and coordinated responses based on physician advice, insurance limitations, and procedural costs.
- Provided education on health and nutrition for patients to maintain healthy habits and wellbeing.
- Collaborated with healthcare providers to drive continuity of care.
- Participated in interdisciplinary care conferences to discuss patient care plans and referrals.
- Participated in clinical supervision to maintain professional development.
Education
Fellowship in Case Management - Clinical Case Management
American Academy of Case Management (FAACM)
Orlando, FLCertified Professional Coder (CPC) - Coding
American Academy of Professional Coders (AAPC)
Orlando, FL10.2021
Certified Risk Adjustment Coder (CRC) - Coding
American Academy of Professional Coders (AAPC)
Orlando, FL09.2016
Specialization in Social Management - Management
ESAP
Colombia, South America 04.2000
M.D. - Doctor in Medicine
Universidad Tecnologica De Pereira
Colombia, South America 12.1998
Skills
- Patient Data Identification
- Medical Terminology
- Records Management
- Diagnostic Codes
- Data Verification
- Outpatient Coding
- Protected Health Information
- Coding Error Resolution
- Medical Claims Coding
- Charting and Clinical Documentation
- Document Quality
- Records Review
- Medical Billing Code Accuracy
- Records Accuracy
- Reviewing Patient Information
- ICD-10 (International Classification of Disease Systems)
- Electronic Health Record Applications
Timeline
Manager of Medical Coding
Centerwell Primary Care
06.2015 - Current
Medicare Risk Adjustment Coder
Family Physicians Group - Centerwell Primary Care
05.2008 - Current
Clinical Case Manager
Family Physicians Group
05.2008 - 06.2009
Fellowship in Case Management - Clinical Case Management
American Academy of Case Management (FAACM)
Certified Professional Coder (CPC) - Coding
American Academy of Professional Coders (AAPC)
Certified Risk Adjustment Coder (CRC) - Coding
American Academy of Professional Coders (AAPC)
Specialization in Social Management - Management
ESAP
M.D. - Doctor in Medicine
Universidad Tecnologica De Pereira
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