Jillian Schouten

• Risk Adjustment / HCC Coding: Established the Risk Adjustment department, created Medicare-compliant HCC guidelines, and implemented processes across 38+ sites and 200+ providers. Conducted retrospective, concurrent, and prospective HCC audits to ensure complete and compliant capture of chronic conditions. Led adoption of an AI/NLP prospective Risk Adjustment tool, developing workflows, provider query templates, and collaborating with product owners on improvements.
• E/M & Profee Coding: Provided oversight and education for E/M and outpatient professional coding, onboarding providers and coders, and delivering direct education through Grand Rounds, recorded trainings, and one-on-one sessions. Partnered with vendors to review E/M coding accuracy, resolve questions, and drive coding performance improvements.
• Clinical Documentation Improvement (CDI): Directed CDI initiatives by educating providers on documentation best practices, resolving compliance issues, and promoting accurate code capture. Integrated CDI resources (ACDIS, AHA Coding Clinic) into daily operations and created internal documentation improvement workflows.
• Leadership & Tools Management: Managed vendor relationships, provided feedback on coding performance, and supervised implementation of coding tools (encoder software, CDI platforms, CEU access). Supported new Coding Manager and contributed to long-term departmental development.

• Audit Oversight & Compliance: Performed audits for Medicare Risk Adjustment (MRA), ACA, and RADV, ensuring accurate, compliant submissions across multiple EMRs (EPIC, Athena, Cerner). Validated data integrity to mitigate regulatory risk and protect financial outcomes.
• Team Performance & Leadership: Monitored Risk Adjustment team performance and reported findings to senior leadership; recommended and implemented process changes to improve accuracy and efficiency.
• Education & Provider Feedback: Delivered coding feedback and provider education based on audit findings, reinforcing compliance with CMS guidelines and improving HCC capture.
• Process Improvement & Special Projects: Led documentation of audit workflows, identified opportunities for operational improvements, and executed special studies/projects at the request of management.
• Internal & External Audits: Conducted both internal audits of Risk Adjustment medical record reviews and external provider audits, ensuring completeness and accuracy of submissions.

Progressive roles: HCC QA Level 1 Auditor → Client Relations Auditor / QA Level 2 Auditor → Risk Adjustment Trainer

• Risk Adjustment Auditing: Audited coder and vendor production for accuracy in HCC, RxHCC, ESRD, and HHS coding assignments, including RADV IVA projects. Ensured submissions aligned with ICD-10, CMS, AHA Coding Clinic, and client-specific guidelines.
• Quality Assurance & Compliance: Identified coding errors and error trends across teams and vendors, creating supplemental training and workflow improvements to address root causes. Supported regulatory compliance and reduced client risk through audit oversight.
• Training & Education: Designed and delivered training for new hires, coders, auditors, and supervisors across multiple projects. Created training materials, reference documents, and videos for onboarding, pilots, and contract-specific updates. Provided daily feedback, chart-level guidance, and rebuttal management.
• Leadership & Mentorship: Led project-specific Q&A sessions and served as a go-to resource for escalated coder/auditor inquiries. Supported company-wide training initiatives, onboarding processes, and project launches to ensure consistent quality.
• Client Relations: Partnered with clients to clarify guideline gaps and expectations, reinforcing trust and supporting contract retention. Tracked workflow and coding accuracy to anticipate issues and deliver proactive resolutions.
• Operational Impact: Improved accuracy and efficiency by refining documentation processes, strengthening coding standards, and enhancing coder education programs, directly supporting client satisfaction and retention.

• Conducted Initial Validation Audits for the HHS-RADV program, ensuring compliance with CMS and client-specific guidelines.
• Applied ICD-10-CM inpatient and outpatient coding rules, AHA Coding Clinic, and accepted coding practices to validate risk-adjusting diagnoses.
• Reviewed member and claim data (demographics, service dates, claim type, provider specialty, provider signatures) for accuracy and regulatory compliance.
• Matched CPT codes to encounters and validated or rejected diagnoses, capturing additional qualifying conditions as appropriate.

• Coded outpatient Evaluation & Management (E/M) encounters, accurately assigning levels of service and capturing all documented ICD codes.
• Audited Pain Management encounters to validate coding accuracy, ensuring appropriate billing and maximizing reimbursement.

• Reviewed medical records to abstract and capture HCC mapping diagnoses in alignment with Risk Adjustment and CMS guidelines.
• Researched and resolved complex coding assignments by applying ICD-10-CM, CMS Risk Adjustment guidance, and client-specific coding rules for both inpatient and outpatient encounters.
• Educated Medicare Advantage coders and acted as a resource for internal departments on HCC coding and chart review best practices.
• Audited coder performance for quality standards, reporting error trends and findings to upper management on a weekly, monthly, and annual basis.
• Conducted on-site client coding audits, reviewing data and assisting directors with intervention and resolution of issues.

• Reviewed inpatient and outpatient medical records to abstract and capture HCC diagnoses in alignment with CMS Risk Adjustment guidelines.
• Coded and audited charts based on client-specific conditions and policies, adapting to contractual requirements as they evolved.
• Performed complete code capture and HCC mapping for multiple commercial clients, ensuring compliance with internal, client, and contractual standards.

• Completed full revenue cycle workflow: coded, submitted, reviewed, and appealed medical claims.
• Processed medical records requests, handling PHI in strict compliance with HIPAA and privacy regulations.
• Assisted with claims processing to ensure accuracy and maximize reimbursement.