Lemeko Starks

The Quality Assurance (QA) Specialist is responsible for the performance of internal coding QA reviews. These reviews provide an additional layer of internal coding quality and compliance of inpatient (IP) records to assure the appropriateness and accuracy of code assignments in accordance with official coding guidelines and client facility-specific coding guidelines.

PRIMARY JOB RESPONSIBILITIES:

• Performs IP coding quality assurance (QA) reviews.
• Maintains turnaround time expectations to minimize the impact on client DNFB.
• Maintains an up-to-date working knowledge of MS-DRG, APR-DRG, and ICD-10 CM/PCS coding.
• Identifies, applies, and validates the use of current industry-standard clinical indicators, risk factors, and treatment protocols/order sets used in the clinical validation of payment-impacting code assignment.
• Abstracts and performs a comprehensive review of the medical record to assess the documentation present or absent as it compares to the base code set impacting payment, or a requested change in coding.
• The review scope includes the validation of the MS-DRGs and APR-DRGs assigned for Medicare, Medicaid, commercial, and third-party claims.
• Recognizes when a clinical documentation query is necessary.
• Write a query asking for clinical indicators and/or documentation excerpts if a discrepancy or gap exists in the medical record documentation and the (base, desired) code assignment per the application of Official Coding Guidelines, or if a medical condition does not appear to be clinically supported or meet clinical criteria requirements.
• Query request writing ability requires knowledge of different types of queries and compliant query practices, including knowledge and application of clinical validation criteria.
• Develops and maintains a strong understanding of Accuity, as well as client-specific technology, policies, procedures, guidelines, and workflows.
• Ensures strict confidentiality of patient information.
• Accountable for meeting or exceeding both production and quality expectations.
• Meets or exceeds short-term and long-term goals, as established for the department.
• May require schedule flexibility and changes to accommodate workflow and client business needs.
• Participates in staff meetings, and attends other meetings and seminars as required.

• Reviewed pre-bill cases with physicians to validate diagnosis and procedure codes for inpatient services.
• Utilized Accuity technology to track coding errors and identify query opportunities.
• Researched and analyzed compliance inquiries, addressing inappropriate coding and client denials.
• Maintained high dependability by meeting Accuity coding recommendations and accuracy rate standards.
• Collaborated with physicians, peers, and management on documentation and regulatory compliance.
• Provided process improvement recommendations to enhance productivity and operational efficiency.
• Developed and modified client procedures to align with Accuity methodologies.
• Facilitated group education sessions on accurate coding practices and regulatory compliance.

• Company Overview: Chicago, IL
• Understand customer needs and provide creative, strategic recommendations
• Perform risk assessments, planning, fieldwork and report writing
• Work on special projects and management requests
• Utilize a data first and data-driven approach to all projects
• Participate in business development growth in various ways from supporting a pursuit to identifying an opportunity to serving as a Crowe Account Lead
• Respond timely to all inquiries by Customers and other Team members
• Perform technical reviews for other coding professionals
• Participate in the Subject Matter Expert (SME) Program in writing thought leadership and speaking on coding topics as needed
• Assist in creating and updating tools, guidelines, resources and solutions to support the growth of the clinical operations team
• Chicago, IL

• Company Overview: New York, New York
• Performs data quality reviews on inpatient records to validate the ICD-10-CM/PCS codes, DRG group appropriateness, missed secondary diagnoses and procedures, and ensures compliance with all DRG mandates and reporting requirements.
• Monitors Medicare and other DRG paid bulletins and manuals and reviews the current OIG Work plans for DRG risk areas.
• Continuously evaluates the quality of clinical documentation to spot incomplete or inconsistent documentation for inpatient encounters that impact the code selection and resulting DRG groups and payment.
• Queries physicians when documentation in the record is inadequate, ambiguous, or unclear for coding purposes.
• Keeps abreast of coding guidelines and reimbursement reporting requirements.
• Displays a positive attitude within the organization in support of the organization’s programs and mission
• Promote effective working relations and works effectively as part of a department/unit team to facilitate goals and objectives
• Maintain confidentiality of all hospital and patient information
• New York, New York

• Company Overview: Marina del Rey, CA
• Level 1 trauma and teaching facility DRG and full coding audits
• Auditing, educating, training of new staff, including interns and outsourced coders for inpatient type. Including education for facility specific as well as coding guidelines
• Weekly education meetings with Data Integrity to identify areas of focus and ICD-10 questions and reviews
• Inpatient auditing for all patient types maintaining minimum 95% accuracy on full coding audits
• Marina del Rey, CA

• Company Overview: Saint Louis MO
• Utilize extensive knowledge of Correct Coding Initiative (CCI) edits, CPT, HCPCS, ICD, Revenue Codes, modifiers, billing, regulations and guidelines (Medicare, Medicaid, third-party billing rules, coverage, payment, and compliance).
• Research complex coding and regulatory requirements in order to understand and analyze payer regulations as well as coding guidelines
• Recommends corrective action in order to reduce regulatory non-compliance
• In collaboration with the Operations and the Education Department, designs and develops training initiatives/interventions to address non-compliance
• Saint Louis MO

• Company Overview: San Diego, CA
• Review of all inpatient accounts for possible financial optimization via ICD-10 coding, DRG/MS-DRG/APR-DRG assignment.
• Responsibilities include accurate ICD-10 and CPT code assignment for accurate APC assignment to ensure optimal reimbursement.
• Responsibilities include accurate coding and DRG assignment, complete and accurate state reported data.
• Accurate ICD-10-PCS assignment according to ICD-10-PCS guidelines
• Trauma, Transplant, Burns, University Hospital
• North Shore Long Island Jewish – Education, Auditing, Coding, Education of Staff
• San Diego, CA

• Company Overview: Southfield, MI
• Translate ICD-9-CM inpatient charts to ICD-10-CM/PCS codes for the ICD-10 Program financial Neutrality assessment and analysis.
• Review inpatient records identified by random sampling of high impact DRG’s
• Follow workflow methodology established by the ICD-10 Team
• Follow corporate policies addressing protection of PHI
• Stay current with ICD-10-CM/PCS Medical Code Set information and updates
• Stay within established productivity benchmarks
• Mapping/GEM’s – utilizing 3M Encoder/Ingenix/Encoder Pro for Payers
• Southfield, MI

• Company Overview: Cleveland, OH
• Performing DRG hospital auditing services via (CAS) Custom Auditing System
• Pre-selection of claims and medical record review
• Determining if the diagnostic and procedural information submitted for DRG reimbursement is substantiated by the documentation in the record; and identification of claims which were paid inappropriately.
• Proficient with all healthcare coding (CPT4, HCPCS, DRG, ICD-9, & Revenue Codes
• Proficient with healthcare claim adjudication standards & procedures
• Cleveland, OH

• Company Overview: Dallas, TX
• Outpatient Radiology Coder for Karmanos Cancer Center
• Reviewed clinical documentation records to assign appropriate diagnostic and procedure codes
• Reviewed medical records of moderate to high complexity levels for all types of outpatient cases in order to identify relevant diagnostic and procedural information
• Assign diagnostic and procedural codes in accordance with approved coding schemes and established coding guidelines
• Coded all outpatient and ambulatory surgery cases within a computerized encoding and abstracting in a Windows based environment (Cerner Applications)
• Used Cerner Powerchart to review clinical medical records along with 3MHDM (abstracting), 3M Encoder
• Dallas, TX

• Company Overview: Plymouth, MI
• Coded Critical Care services provided in the E/R along with evaluation and management services provided to a patient in an observation area of the hospital as well as radiology and laboratory test
• Reviewed medical records for the determination of diagnoses and procedures performed
• Abstracted and enter coded data and designated quality management data for hospital statistical and reporting requirements
• Used QuadraMed at VA to review clinical medical records
• Plymouth, MI

• Company Overview: Sterling Heights, MI
• Responsible for acting as a focal point for the medical coding staff in all duties and operations at the Veteran Administration Medical Center of Detroit and acute care facility with both inpatient and outpatient coding
• Audited selected cases from the medical coding staff to ensure proper medical coding and use of ICD-9-CM, CPT code
• Interacted with intradepartmental staff to obtain complete and accurate information by identifying deficiencies and assisting providers with required chart completion
• Sterling Heights, MI

• Company Overview: Southfield, MI
• Analyzed cost and enrollment data relating to the American Axle Major Medical, Dental and RX plans
• Analyzed, reviewed and audited healthcare and dental service providers to ensure that claims are processed in accordance with the plan design
• Assisted with calculations and analysis of financial impact of proposed changes to benefit plans
• Maintained an awareness of developments in the healthcare and insurance field that related to job responsibilities (to include benefit analysis and technology uses), and integrated them into own practices
• Southfield, MI

• Company Overview: Detroit, MI
• Detroit, MI

• Company Overview: Southfield, MI
• Southfield, MI