Karen Bowers
RHIA, CCS, CPC
Summary
Results-driven executive with a proven track record of optimizing the financial performance of Medicare Advantage and commercial small group plans. Offering over 19 years of expertise in medical records coding, data analytics, and risk management. Recognized for strong leadership, successful project implementations, and proficiency in qualitative analysis. Committed to continuous professional growth and development. Known for precision in coding and data analytics, with a talent for rectifying deficiencies in medical documentation. Accomplished educator skilled in training physicians, staff, and novice coders using innovative techniques. A strategic thinker with the ability to lead and implement complex projects. Positioned for continued success in the healthcare industry.
Overview
20
20
years of professional experience
9
9
years of post-secondary education
5
5
Certifications
Work History
DIRECTOR OF RISK MANAGEMENT
American Health Plans
Remote, TN
11.2022 - Current
- Spearhead the development, organization, and direction of risk management activities for Medicare Part C risk adjustment, documentation improvement, and HCC coding.
- Orchestrate analytical strategies optimizing the company's risk posture under Healthcare Reform and Medicare Advantage.
- Formulate compliance policies and procedures for risk coding and RADV mitigation.
- Leverage SQL code to assess, clean, validate, and analyze extensive datasets for risk adjustment operations.
- Conduct audits, providing detailed reports to providers and the compliance department.
- Collaborate across business areas to identify and capitalize on risk and quality improvement opportunities.
- Lead and mentor HCC coders and risk adjustment analysts.
- Ensure accurate and compliant EDPS submissions.
- Champion a culture of regulatory compliance and stay abreast of industry regulations and policy implementation.
- Develop and deliver tailored training programs on risk adjustment, clinical documentation improvement, and medical coding for providers and executive leadership, ensuring compliance with industry regulations. Facilitate interactive sessions, provide individualized coaching, and utilize data analytics to drive continuous improvement in coding accuracy and documentation integrity. Collaborate with cross-functional teams, engage executive leadership, and foster a culture of continuous learning to optimize revenue cycle management and overall healthcare quality.
MEDICARE ADVANTAGE & QUALITY RISK PROGRAMS MANAGER
Blue Cross Blue Shield of Alabama
Remote, AL
06.2022 - 11.2022
- Orchestrated and directed activities within the Division to strategically optimize risk posture under Healthcare Reform and Medicare Advantage initiatives.
- Spearheaded the identification and resolution of Fraud, Waste, and Abuse (FWA) cases, fostering collaboration with the internal FWA department to conduct thorough and comprehensive audits.
- Proficiently executed SQL code to assess, clean, validate, and analyze expansive datasets, contributing to the seamless operation of risk adjustment processes.
- Assumed a pivotal role in ensuring compliance with standards and regulations governing risk adjustment programs, providing meticulous oversight of the CMS HHS Risk Adjustment Data Validation (RADV) and OIG Audits.
- Collaborated cross-functionally with various business units to pinpoint and capitalize on risk and quality improvement opportunities, demonstrating a holistic approach to organizational enhancement.
- Played a central role in coaching and developing associates, ensuring the implementation of a robust program that aligns with organizational objectives.
- Provided vigilant oversight for research and analysis, incorporating policies to maintain internal procedures and uphold regulatory compliance standards.
ASSOCIATE DIRECTOR RISK ADJUSTMENT
VIVA Health
Remote, AL
11.2015 - 05.2022
- Orchestrated the development of manuals and processes for the coding department, ensuring preparedness for Risk Adjustment Data Validation (RADV) audits based on insights gleaned from previous audit findings.
- Conducted thorough and unbiased investigations into allegations of fraud, waste, or abuse, employing objective analysis of medical record documentation to synthesize comprehensive reports with actionable recommendations.
- Collaborated with defense attorneys to devise deposition strategies and leveraged law enforcement resources for case support.
- Managed a diverse and high-volume caseload efficiently, prioritizing tasks to achieve positive outcomes.
- Analyzed data to strategically prioritize efforts in validating diagnoses within medical records, minimizing audit risks and associated takebacks.
- Actively participated in CMS Contract-level RADV audits for payment years 2014 and 2015, as well as HHS RADV audits for payment years 2017 and 2019.
- Engaged in regular calls with CMS to contribute insights on RADV audit selection protocols, policies, and provided feedback on process improvements and software components.
- Ensured accuracy, completeness, and timeliness of data collected from claims and supplemental sources.
- Formulated and updated departmental policies and procedures annually, overseeing risk adjustment projects and initiatives with subsequent communication of results and recommendations to executives.
- Facilitated Quarterly Risk Adjustment meetings with the executive team, ensuring alignment with company goals.
- Collaborated with the Information Systems department to guarantee accurate file transfers to Centers for Medicare and Medicaid Services (CMS).
- Monitored quality assurance measures, identifying and resolving coding discrepancies while tracking and trending risk adjustment data across the member population.
- Developed and delivered internal and external workshops to educate staff and providers, minimizing future coding errors based on audit results.
- Provided feedback and education to office management regarding coding practices, and developed forecasting methods in collaboration with vendor partners.
- Worked closely with Quality Improvement and Connect for Quality teams to mutually support company goals.
- Previously served as the Supervisor of Risk Adjustment and Risk Adjustment Coding Coordinator, responsible for quality assurance and compliance audits for pro-fee services, including provider education post-audit completion.
SENIOR CONSULTANT
UASI
Remote, OH
06.2015 - 11.2015
- Spearheaded ICD-10-CM dual coding audits and educational initiatives for professional fee services as the Project Manager.
- Managed and provided leadership for a team of 15 auditors, ensuring optimal production output and maintaining high standards of quality.
- Executed comprehensive coding audits encompassing ICD-10-CM, CPT, and E&M, contributing to the enhancement of coding accuracy and compliance.
- Demonstrated proficiency in both ICD-9-CM and ICD-10-CM coding methodologies, as well as a sound understanding of IPPS (Inpatient Prospective Payment System).
- Applied in-depth knowledge of CPT/HCPCS coding methodologies and OPPS (Outpatient Prospective Payment System), ensuring adherence to regulatory guidelines.
- Consistently achieved and surpassed expectations in terms of both quality and productivity benchmarks.
CODING SPECIALIST LEAD
AlphaII
Montgomery, AL
09.2009 - 05.2015
- Led a dynamic team overseeing all CPT data as the designated Team Leader.
- Held the position of Managing Editor for 13 medical coding books dedicated to ICD-10-CM, ensuring accuracy and relevance in content.
- Spearheaded the development and validation of precise ICD-10-CM data and edits for encoder and billing software applications, contributing to seamless operational workflows.
- Formulated an ICD-9 to ICD-10 crosswalk, facilitating smooth transitions and accurate coding processes.
- Innovatively designed ESRD calculation and edits for claim adjudication software used in VA hospitals, streamlining billing procedures.
- Proactively identified and interpreted quarterly and yearly changes, incorporating them judiciously into ICD-9-CM and HCPCS books, encoder, and billing software, aligning with evolving industry standards.
- Maintained data integrity and remained abreast of all CPT guidelines, additions, changes, and deletions, ensuring the continuous accuracy of software and encoder systems.
- Effectively resolved coding and billing issues for customers through a dedicated coding hotline, showcasing a commitment to customer satisfaction and issue resolution.
- Attended CMS coordination and maintenance committee meetings, CPT editorial panel meetings, and other relevant coding and billing forums to acquire and maintain updated knowledge of coding guidelines and industry news.
CODING EDUCATOR
Baptist Health
Montgomery, AL
08.2003 - 06.2009
- Engaged on a PRN basis since 2009, providing coding and education expertise as needed.
- Conducted coding for outpatient and inpatient charts within the facility, ensuring accurate and compliant coding practices.
- Managed the coding and keying of profee services, encompassing office visits, home visits, nursing home visits, assisted living visits, and home health services across four facilities.
- Oversaw the coding and keying of hospital charges for inpatient, outpatient, and psychiatric services, maintaining precision for four facilities.
- Performed qualitative analysis of charts to identify and rectify discrepancies in documentation for residents, contributing to enhanced accuracy and compliance.
- Analyzed medical documentation, compiled data, and generated reports for monitoring resident procedures and visits.
- Conducted audits on charges by physicians, researching CPT and ICD-9 coding discrepancies to ensure compliance and reimbursement accuracy.
- Provided education on billing and coding for residents, creating educational materials and conducting classes for physicians, residents, nurses, and billing staff.
- Led training sessions for staff on billing and coding processes, ensuring adherence to industry standards.
- Managed the credentialing process for providers across all insurance carriers for four facilities.
- Balanced and prepared month-end reports for all four facilities, showcasing attention to detail and financial acumen.
- Addressed audit trails, corrected errors, and resubmitted claims, ensuring timely and accurate reimbursement.
- Collected outstanding accounts with all insurance carriers and managed patient pay accounts, showcasing strong financial management skills.
- Maintained medical records and performed billing of claims, contributing to comprehensive healthcare administration.
- Assisted with medical procedures when needed, showcasing versatility in medical assisting roles.
Education
Bachelor's degree - Health Information Management
01.2017 - 01.2020
Accounting - undefined
01.1997 - 01.2003
Skills
Strategic PlanningRisk ManagementFinancial Performance OptimizationRegulatory ComplianceProject ManagementData AnalyticsTeam Leadership and DevelopmentEducation and TrainingRisk Adjustment and HCC CodingCompliance ManagementHealthcare Reform ExpertiseMedical CodingSQL
Process implementation
Certification
Registered Health Information Administrator (RHIA)
Timeline
DIRECTOR OF RISK MANAGEMENT - American Health Plans
11.2022 - Current
MEDICARE ADVANTAGE & QUALITY RISK PROGRAMS MANAGER - Blue Cross Blue Shield of Alabama
06.2022 - 11.2022
Western Governors University - Bachelor's degree, Health Information Management
01.2017 - 01.2020
ASSOCIATE DIRECTOR RISK ADJUSTMENT - VIVA Health
11.2015 - 05.2022
SENIOR CONSULTANT - UASI
06.2015 - 11.2015
CODING SPECIALIST LEAD - AlphaII
09.2009 - 05.2015
CODING EDUCATOR - Baptist Health
08.2003 - 06.2009
Troy University - Accounting,
01.1997 - 01.2003