I have 15 years experience in Health Information Management and have worked in health care for close to 20 years. Before I went into medical records I was a CNA for 2 years.
Overview
12
12
years of professional experience
Work History
Medical Records Technician
Molina Healthcare
04.2022 - 04.2023
Trained new employees in the receptionist position as well as the scanning of the electronic medical record
Maintained medical records for all clinics within the facility
Assisted all providers with any medical records they needed to care for their patients
Pulling charts for the providers and filing in patient charts before the facility went electronic
Assisted in financial counseling for OB patients
Medical Records and Health Information Technician
Cahaba GBA
07.2011 - 02.2018
Maintained patient confidence by keeping patient records information confidential.
Processed medical records requests from outside providers according to facility, state, and federal law.
Maintained patient records in compliance with security regulations.
Uploaded physician progress notes, history, and physicals into electronic medical records.
pplies comprehensive knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures as well as the principles and practices of health services and the organizational structure to ensure proper code selection.
Reviews assigned codes from the current version of several coding systems to include current versions of the International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS).
Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or evaluation and management (E/M) code to ensure ethical, accurate, and complete coding.
Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC. Timely compliance with coding changes is crucial to the accuracy of the facility database as well as all cost recovery programs.
Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided; provides technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing. Directly consults with the professional staff for clarification of conflicting or ambiguous clinical data.
Expertly searches the patient record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient health record.
Audit accurate and complete assignment of ICD-10-CM and ICD-10-PCS codes, MS- DRG, POA status, and discharge disposition values for inpatient health records. Audit accurate and complete assignment of ICD-10-CM, CPT, and HCPCS codes, including appropriate E/M assignment and modifier usage for outpatient health records. Audit function includes evaluation of clinical documentation to support optimal code assignment.
Reviews coding and assist coders in improving coding accuracy; provides coding guidance to various levels of staff to
Education
Associate of Applied Science - Medical Billing And Coding: Admin Office Managemen
Virginia College - Birmingham
Birmingham, AL
01.2002
High School Diploma -
West End High School
Birmingham, AL
05.1998
Skills
Medical records proficiency
Filing of documents
Professional phone skills
Familiar with ICD-10
Excellent leadership skills
Great training abilities
Very dependable
Extreme attention to detail
Fast learner and always willing to learn new tasks
Very approachable with great communication skills
Excellent multi-tasker
Timeline
Medical Records Technician
Molina Healthcare
04.2022 - 04.2023
Medical Records and Health Information Technician
Cahaba GBA
07.2011 - 02.2018
Associate of Applied Science - Medical Billing And Coding: Admin Office Managemen