Kari Sewell
Somerset,Kentucky
Summary
Present with a diverse background in acute care, including medical-surgical ICU, Neonatal ICU, and maternal-infant care in the labor and delivery unit,. The past fifteen years have focused on work in the managed care setting, holding various roles as a Quality Assurance Auditor, specializing in Risk Adjustment coding and Payment Integrity Auditing, plus retain extensive experience in HEDIS as an abstractor and Quality Assurance Analyst. Proven ability to efficiently manage multiple tasks using electronic medical record systems, well-versed in adhering to medical records policies and procedures to ensure HIPAA compliance. 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
2
2
Certificate
Work History
Coding Quality Analyst
Optum
05.2023 - Current
- Currently work as a Quality Assurance Auditor in Risk adjustment
- Duties are to perform quality scoring and provide instruction/feedback to production staff, aid with RADV audits for Medicare advantage, Medicaid, and Commercial clients and to help production staff with coding when needed while keeping a strict accuracy score of 96% on all work
- Daily responsibilities include leveraging several client specific guidelines and metrics across all lines of business which requires excellent organizational skill, diligence, and the ability to adapt fluidly to change and maintain required productivity metrics for the specified business
- Reviewed and analyzed trends to advise and develop recommendations to achieve or modify program goals.
- Reduced errors within projects by conducting regular audits for adherence to established guidelines and requirements.
- Used classification manuals to gain additional knowledge of disease and diagnoses processes.
Quality Assurance Auditor
Change Healthcare
12.2013 - 05.2023
- Worked as a Quality Assurance Specialist in the areas of Payment Integrity Auditing (PIA) and HEDIS scoring and providing instruction/feedback to coders/abstractors applying ICD 10 CM and NCQA guidelines
- Payment Integrity Auditing (PIA)- worked in quality performing instruction/feedback and quality scoring for the production, aided with Special Project specific jobs for contracted clients, and assisted with RADV audits
- Have measurable experience in HEDIS working as a Quality Assurance auditor providing instruction and feedback along with quality scoring to abstractors in the measures Prenatal and Frequency of Prenatal Care FPC, and Weeks of Pregnancy WOP following NCQA technical specifications for each of those measures
- During HEDIS worked managing the platform Web SR in which the top responsibility was to resolve measure specific discrepancies between full time abstractors and contracted client's auditors in the measures PPC, FPC, WOP
- These duties required excellent verbal and communication skills, in depth knowledge of each measure, and the ability to make correct determinations while providing exact guideline specific rationale for those decisions.
Medical Coder/Abstractor
Altegra
12.2009 - 12.2013
- At Altegra, duties were performing coding abstraction for Medicare Advantage, Medicaid, and Commercial lines of business according to ICD 10 Guidelines while keeping accuracy scoring of 95% and meeting project specific production requirements
- Applied official coding conventions and rules from American Medical Association and Centers for Medicare and Medicaid Services to assign diagnostic codes.
- During the HEDIS season responsibilities included chart abstraction for a variety of measures to include PPC, FPC, WOP, CCS, CBP, AND A1C DM using NCQA technical specifications and keeping accuracy scoring of 95% and project specific production requirements
- Streamlined abstracting processes for increased efficiency and productivity by implementing innovative research techniques.
- Provided support in obtaining records from outside sources to complete chart for patient care.
- Delivered high-quality abstracts under tight deadlines, managing multiple projects simultaneously without sacrificing attention to detail.
- Assisted in the training of new team members, sharing expertise in abstracting best practices and procedures.
- Enhanced communication with clients by providing timely updates on project status and addressing inquiries promptly.
- Resourcefully used various coding books, procedure manuals, and on-line encoders.
- Reviewed patient charts to better understand health histories, diagnoses, and treatments.
Education
Bachelor of Science - Nursing
Eastern Kentucky University
Richmond, KY05.2009
Associate of Science - Nursing
Eastern Kentucky University
Richmond, KY05.1998
Skills
- Professionalism
- Medical Terminology
- Data Entry
- Microsoft Excel
- Patient Health Information Access
- 3M Encoder
- ICD-10 Coding
- Adaptability and Flexibility
- Health Information Systems
- Electronic Health Records
- EMR Systems
- Epic Systems
- Records Review
- Medical billing code accuracy
- Records Accuracy
- Medical Documentation
- Critical Thinking
- Medical coding knowledge
- Revenue Cycle Management
Certification
- AAPC, Certified Professional Coder CPC, 12/14
- AAPC, Certified Risk Adjustment Coder CRC, 06/18
Timeline
Coding Quality Analyst
Optum
05.2023 - Current
Quality Assurance Auditor
Change Healthcare
12.2013 - 05.2023
Medical Coder/Abstractor
Altegra
12.2009 - 12.2013
Bachelor of Science - Nursing
Eastern Kentucky University
Associate of Science - Nursing
Eastern Kentucky University
Hobbies and Interests
- Literature
- Boating
- Scuba Diving
- Skiing
- Hiking
- Gardening
- Travel
Personal Information
I am a wife and mother of one plus a furbaby. I enjoy spending time with my family and friends and often can be found on the lake or hiking outdoors during the warm months of the year, when the weather turns cooler, I can be found reading all types of novels, my favorite are thrillers, or crafting up some pretty wreaths or garlands in my "she" shed! I have been a Registered Nurse for 26 years and had the opportunity provide patient care in a variety of acute care settings, the last 15 years of my career have been spent working in managed care as a Risk Adjustment auditor. I am interested in expanding my auditing capabilities by learning different aspects of the role.
References
Upon Request
Hobbies and Interests
- Literature
- Boating
- Scuba Diving
- Skiing
- Hiking
- Gardening
- Travel
Personal Information
Title: Registered Nurse
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