Lauren Peterson
Raynham,MA
Summary
Results driven leader with over 15 years of coding/auditing experience in both payer and provider spheres. Excellent ability to train, coach, and mentor medical coders in a positive learning environment on risk adjustment methodologies. Exemplary operational, organizational, strategic, and planning skills who excels at increasing interaction while building trusting relationships across teams.
Overview
12
12
years of professional experience
Work History
Director, Coding Audit
Signify Health
Dallas, TX
10.2023 - Current
- Develop and implement comprehensive strategies to improve operational processes and organizational efficiency of the internal Risk Adjustment audit team and Coding Compliance team.
- Implement robust risk mitigation strategies, including audit plans related to high-risk HCCs to ensure our client base is protected in government audits.
- Creation of provider audit in collaboration with additional stakeholders to determine whether documentation was sufficient according to CMS guidelines.
- Oversee audit activities related to coding, including interrater reliability protocols, and offshore coding vendors.
- Construct KPI/SLA performance metrics for leadership to ensure optimal performance and responsiveness to the client base.
- Direct oversight, mentorship, and operational management of an Audit team composed of ~50 managers and auditors.
Manager Risk Adjustment Quality Control
Elevance Health
Indianapolis, IN
09.2022 - 10.2023
- Lead MRA coding and provider education in the Central region to ensure consistent risk adjustment coding quality and improve documentation through provider education.
- Train and develop a team of risk adjustment educators and chart retrieval specialists in effort to contribute to overall professional growth and achieve company goals.
- Project manage by spearheading creation and implementation of programs such as Comprehensive Assessment Program and Enhanced Support Program including policies and procedures, which leads to accurate, complete validation of member’s health status.
- Collaborate and partner with MRA Compliance and National MRA teams to stay up to date on regulatory information, vote on important coding updates on the Coding Advisory panel, create coding tools and provider education program.
- Frequent, positive engagement with senior leadership to align and provide high level reporting on team initiatives.
Manager Risk Adjustment Coding & Quality Assurance
Blue Cross Blue Shield of Massachusetts
Boston, MA
01.2021 - 09.2022
- Operational oversight of medical record review processes for Medicare and Commercial risk adjustment coding to ensure accurate HCC validation to achieve revenue goals more than $20M
- Efficiently manage and confidently motivate a team of 11 certified medical coders by ensuring high production and quality metrics are met to satisfy program deadlines and revenue goals.
- Project manage key initiatives by implementing process improvements, maintaining quality and productivity standards, creating workable solutions, and resolving challenges for all coding related risk adjustment activities.
- Hire new associates and performance manage existing associates to develop individuals and encourage them to reach their highest potential.
- Conduct trend analysis to collaborate on areas of improvement and deliver feedback/education to assist providers in their understanding of risk adjustment.
- Establish thorough and valuable internal coding guidelines by researching official coding resources to ensure inter-rater reliability across risk adjustment coders.
- Subject matter expert on RADV coding guidelines to identify best practice and innovations to positively affect quality improvement.
Senior Risk Adjustment Coding Quality Auditor/Educator
Blue Cross Blue Shield of Massachusetts
Boston, MA
05.2017 - 12.2020
- Lead Auditor/Educator responsible for performing QC program review of 9 internal coders as well as multiple vendors to ensure complete, accurate code capture and providing thoughtful coding feedback based on QC results.
- Motivational onboarding training to all new associates as well as existing associates as needed by providing education to achieve a quality score of 95%.
- Design, develop, and deliver education and training on risk adjustment documentation to provider network to ensure proper reimbursement to manage members.
Risk Adjustment Auditor/Coder
Blue Cross Blue Shield of Massachusetts
Boston, MA
09.2014 - 04.2017
- Conducted retrospective chart reviews remotely or on location by coding and capturing all HCCs for Medicare and Commercial programs
- Produced high quality work at 97% accuracy rate along with production standards of 38 charts per day while ensuring all ICD-9-CM and ICD-10-CM diagnoses were documented, coded, and reported by following CMS payment guidelines and official coding resources
- Participated in National Sample Medicare Advantage RADV and HHS RADV program audits to ensure compliance.
Compliance Auditor
Compass Medical P.C
East Bridgewater, MA
08.2012 - 08.2014
- Conducted billing compliance audits for over 90 providers in multiple specialties by reviewing documentation to ensure proper capture of ICD-9-CM and CPT coding.
- Designed and developed tools on billing education to present to providers and support staff to ensure compliant, proper reimbursement.
- Project management of ComplyTrack suite. Implemented workgroups and conducted trainings with associates and leadership to meet specific needs and expectations of the company.
Education
Master of Science - Health Administration
Southern New Hampshire University
05-2026
Certified Risk Adjustment Coder, AAPC -
01.2015
Certified Professional Medical Auditor, AAPC -
01.2012
Certified Professional Coder, AAPC -
01.2010
Bachelor of Arts - Psychology
Massachusetts College of Liberal Arts
05.2008
Skills
- Risk Adjustment
- CMS RADV & HHS RADV SME
- Mentor
- Analytical
- Multitasking
- Collaborative
- Strategic
- ICD-9-CM
- ICD-10-CM
- CPT – specifically E&M
Timeline
Director, Coding Audit
Signify Health
10.2023 - Current
Manager Risk Adjustment Quality Control
Elevance Health
09.2022 - 10.2023
Manager Risk Adjustment Coding & Quality Assurance
Blue Cross Blue Shield of Massachusetts
01.2021 - 09.2022
Senior Risk Adjustment Coding Quality Auditor/Educator
Blue Cross Blue Shield of Massachusetts
05.2017 - 12.2020
Risk Adjustment Auditor/Coder
Blue Cross Blue Shield of Massachusetts
09.2014 - 04.2017
Compliance Auditor
Compass Medical P.C
08.2012 - 08.2014
Master of Science - Health Administration
Southern New Hampshire University
Certified Risk Adjustment Coder, AAPC -
Certified Professional Medical Auditor, AAPC -
Certified Professional Coder, AAPC -
Bachelor of Arts - Psychology
Massachusetts College of Liberal Arts