Yilian E. Leon
Miami,FL
Summary
Pursuing to secure my position as a Medical Record Technician at the VA Hospital, where my skills are effectively utilized to their fullest potential and provide continual experience with growth opportunities.
As a highly skilled Medical Record Technician, I can bring extensive experience in reviewing and analyzing patient health records to ensure accurate, ethical, and complete coding across both inpatient and outpatient settings. My proficiency in ICD-10-CM, CPT, and HCPCS coding systems is supported by a strong foundation in medical terminology, disease processes, and pathophysiology, allowing for precise code assignment and documentation validation. I excel in interpreting complex clinical documentation and applying sound judgment when navigating incomplete or ambiguous guidelines. My commitment to regulatory compliance includes ongoing monitoring of policy changes and timely implementation of coding updates, ensuring accuracy in facility databases and alignment with reimbursement and cost recovery protocols. Collaborating closely with providers and clinical staff, I could offer technical guidance on documentation standards, sequencing, and coding policies to enhance data integrity and workload capture. Known for my attention to detail and organizational skills, I proactively resolve discrepancies and contribute to the overall efficiency and accuracy of health information management systems. Experienced and versatile General Dental and Surgery Assistant with over 19 years of expertise in surgical and clinical support. I am skilled in managing inventory and quality control of biological implants and surgical supplies, as well as acquiring, tracking, and replenishing materials. Proficient in inpatient preparation, instrument sterilization, tray setup, and procedural assistance—including maintaining oral field clarity, passing instruments, taking impressions, and performing dental radiography. Known for precision, efficiency, and a strong commitment to patient care and procedural excellence. Able to communicate using good sound judgment, self-motivation, eagerness, and willingness to learn, oriented towards efficiency and organization, independent, with a commitment to team success and assignment at hand.
Overview
12
12
years of professional experience
Work History
Dental/Maxillofacial-Prosthodontist/Surgery Assistant
VA Hospital
Miami, Florida
11.2019 - Current
- Analyze health records to identify accurate diagnoses and procedures, ensuring documentation aligns with coding standards.
- Perform comprehensive outpatient and inpatient coding, including surgical cases, diagnostic procedures, and professional services across varied clinical settings.
- Apply accepted coding practices, guidelines, and conventions to select appropriate diagnosis, procedure, ancillary, and E/M codes, ensuring ethical and complete coding.
- Conduct thorough reviews of patient health records to abstract clinical, demographic, and administrative data for complete and accurate documentation.
- Support clinical staff in meeting documentation standards by providing technical guidance on coding regulations, reimbursement, workload, and proper sequencing; ensure provider documentation fully supports coded diagnoses and procedures.
- Navigate complex patient records to locate and validate documentation that substantiates code assignment, leveraging deep knowledge of record structure and organizational systems.
- Assist the dentist in all procedures, including Expanded Functions of oral evacuations, maxillofacial-prosthodontist surgery techniques, and mouth/tongue retractions.
- Aid in the following surgical procedures: 3rd molar extraction, Dental Implant, Biopsy, Extractions/Bone graft.
- Responsible for closely working with attending physicians, residents, Cath Lab staff, operating room nursing staff, and vendors, researching to ensure appropriate implantable devices are requested, obtaining the best pricing, meeting all VA/VHA socioeconomic goals, and obtaining timely items.
- Responsible for ensuring that existing consignments are used or returned to vendors before the expiration date of the implant.
- Review daily schedule to set up appropriate trays and instruments according to the procedures.
- Schedule patients for surgery as well as give pre- and post-operative instructions.
- Follow the process flow guidelines developed by the Central Office, VISN Service Line management, facility Surgery, and Acquisition staff.
- Receive phone calls, secured messages, email correspondence, and visits from Veterans and clinical staff about eligibility, services, and benefits.
- Communicate with technical specialists on various purchasing processes.
- Use judgment to interpret guidelines, adapt procedures, decide approaches, and resolve problems while adhering to guidelines, policies, and procedures.
- Chart all appropriate data of patients during exams and treatments.
- Utilize 4-handed techniques for passing and receiving instruments and materials.
- Prepare dental materials: cement, composite, impression materials, etc.
- Perform required laboratory procedures, i.e., take dental impressions, pour plaster models, etc.
- Maintain the instruments and working areas in strict accordance with sterilization/disinfection protocols per OSHA guidelines.
- Crosstrain in other dental support positions, administrative matters as necessary, i.e., reception and oral surgery.
- Provide information to perform consultations and requests for prosthetic components.
- Maintain personnel protection per OSHA guidelines regarding personnel safety, i.e., protective clothing, eyewear, and gloves.
- Purchase supplies, take inventory, stock supplies, instruments, and medications, and order said items.
- Proficient and accurate bending/coordinating arch-wires and fixed bands/brackets removal.
- Ability to fit headgear and give instructions, ligature removal and replacement, wire removal and placement, size, fit, cement orthodontic bands, separator placement, and fabrication of orthodontic retainers.
- Currently trained and certified in HIPAA regulations regarding confidentiality and rights to privacy.
General Lead Dental Assistant
Sage Dental
Miami, Florida
09.2016 - 11.2019
Dental/Orthodontics Assistant
Great Expressions Dental Centers
Miami, Florida
05.2014 - 09.2016
General Dental Assistant
Illustradent South Miami Dental, Dr. Nilo Hernandez
Miami, Florida
05.2013 - 05.2014
Education
Dental Assisting National Board (DANB) (CDA) (GC) (IC) (RHS) Certification - undefined
01.2019
Medical Coder Biller Diploma - undefined
Miami Dade Community College
Miami, Florida01.2025
Bachelor's - Science Program
Miami Dade Community College
Miami, Florida08.2025
Certification in Dental Radiography Program - undefined
Miami Institute of Medical Technology
Miami, Florida01.2007
Diploma - General Courses
Osvaldo Herrera High School
01.2003
Skills
- Vista
- Vista GUI
- Computerized Patient Record System (CPRS)
- Dental Record Manager Plus (DRM)
- Consolidated Patient Account Center (CPAC)
- Easy Dental
- Dentrix
- Microsoft Outlook
- Excel
- Word
- Teams
Languages
Bilingual in English and Spanish
Awards
- Certificate of Appreciation (Contribution to the Veterans Health Administration), 12/01/20
- On the Spot Award (Work Ethics for following ICARE Values), 12/01/22
Timeline
Dental/Maxillofacial-Prosthodontist/Surgery Assistant
VA Hospital
11.2019 - Current
General Lead Dental Assistant
Sage Dental
09.2016 - 11.2019
Dental/Orthodontics Assistant
Great Expressions Dental Centers
05.2014 - 09.2016
General Dental Assistant
Illustradent South Miami Dental, Dr. Nilo Hernandez
05.2013 - 05.2014
Dental Assisting National Board (DANB) (CDA) (GC) (IC) (RHS) Certification - undefined
Medical Coder Biller Diploma - undefined
Miami Dade Community College
Bachelor's - Science Program
Miami Dade Community College
Certification in Dental Radiography Program - undefined
Miami Institute of Medical Technology
Diploma - General Courses
Osvaldo Herrera High School