KATRINA AIKEN
Sugar Hill,Georgia
Summary
Medical Auditor over 10years of experience specializing in post-payment claims auditing, payment integrity, and medical record-to-claim validation for Medicare and Medicare Advantage. Reviews 40+ claims per week against ICD-10-CM, CPT, HCPCS, and E/M coding against clinical documentation to identify unsupported services, documentation gaps, and reimbursement discrepancies. Produces defensible findings using CMS and payer standards across high-volume specialties.
Overview
1
1
Certification
13
13
years of professional experience
Work History
Medical Auditor
Elevance Health
01.2022 - Current
- Perform payer-side post-payment medical claims audits focused on payment integrity, coding accuracy, documentation support, and appropriate reimbursement.
- Review Medicare and Medicare Advantage claims and compare billed services with medical record documentation to validate ICD-10-CM, CPT, HCPCS, and E/M reporting.
- Identify unsupported diagnoses or services, coding discrepancies, documentation deficiencies, potential overpayments, and other reimbursement or compliance concerns.
- Document clear, defensible audit findings using applicable coding guidelines, payer requirements, and regulatory standards.
- Conduct high-volume reviews across multiple outpatient specialties while maintaining quality and productivity expectations.
- Support accurate claim payment by determining whether billed diagnoses, procedures, and levels of service are supported by the clinical record.
Medical Coding Auditor
Guidehouse
01.2020 - 01.2022
- Supported the Defense Health Agency (DHA) on a government healthcare contract, performing coding and documentation audits in a highly regulated environment.
- Reviewed medical records and claims for coding accuracy, documentation support, reimbursement integrity, and compliance with government payer requirements.
- Validated ICD-10-CM, CPT, HCPCS, and E/M coding and identified discrepancies between clinical documentation and billed services.
- Applied government-specific coding and audit guidance and documented findings to support accurate reimbursement, quality, and compliance.
- Reviewed complex outpatient encounters across multiple specialties and maintained consistent, defensible audit decisions.
- DHA Contract
Certified Professional Coder
Piedmont Hospital
01.2014 - 01.2020
- Reviewed and coded medical records, ensuring accurate diagnosis and procedure code assignment, enhancing supporting documentation.
- Applied ICD-10-CM/PCS, CPT, HCPCS, and coding guidelines to support accurate reimbursement and regulatory compliance.
- Performed coding quality reviews and physician documentation audits, identifying deficiencies and enhancing coding accuracy.
- Collaborated with providers and coding teams to resolve documentation and coding issues, serving as a key coding resource.
- Maintained high coding quality and productivity standards while reviewing coding trends and supporting audit improvement initiatives.
Education
Associate of Science - Healthcare Administration
University of Phoenix
01.2011
Skills
Post-payment claims auditing
Payment integrity
Medical record & claims review
Coding compliance
CMS guidelines
Audit findings
Reimbursement validation
Quality assurance
Defensible audit documentation
Claims discrepancy analysis
Overpayment identification
Provider education
Certification
- CPC - Certified Professional Coder
- CPMA - Certified Professional Medical Auditor
- AAPC Member in Good Standing
Timeline
Medical Auditor
Elevance Health
01.2022 - Current
Medical Coding Auditor
Guidehouse
01.2020 - 01.2022
Certified Professional Coder
Piedmont Hospital
01.2014 - 01.2020
Associate of Science - Healthcare Administration
University of Phoenix