TONI R. JEFFRIES
Ellenwood,GA
Summary
Experienced healthcare professional dedicated to supporting healthcare provider leadership in achieving success. Strong ethical skills, education, and extensive experience leveraged to foster corporate integrity and drive excellence. Committed to ensuring the highest standards of patient care and promoting a culture of continuous improvement. Seeking opportunity to contribute to the growth and advancement of a healthcare organization that values integrity.
Overview
21
21
years of professional experience
Work History
Coding Quality Analyst- Payment Network Integrity
Optum
12.2023 - Current
- Conducts review of records that have identified as suspicious and or potentially fraudulent utilizing most current reference materials to include but not limited to Current Procedural Terminology (CPT), International Classification of Disease (ICD-9 CM/ICD 10) and Healthcare Common Procedure Coding System (HCPCS) guidelines.
- Records coding review decisions through detailed notations and inputs notes into relevant company systems.
- Discuss and present on decisions made to appropriate internal and external individuals/groups.
- Apply federal and state mandate guidelines to support coding reviews.
- Proven ability to meet production unit standards while managing multiple priorities.
- Mentors new team members to foster their growth and development.
- Maintains high levels of accuracy within case reviews by continually refining our approach to quality assurance based on feedback from colleagues, clients, or industry trends.
Postpay Coding -Special Investigations Unit (SIU)
OPTUM
03.2018 - 12.2023
- Conducted comprehensive audits to ensure accurate coding, leading to increased revenue capture for clients.
- Reviewed claim history and validated medical documentation against billed procedural codes.
- Reviewed appeals and initial claims, requiring the interpretation of state and federal mandates, medical reimbursement policies, coding standards, and relevant clinical information
- Utilized multiple claims platforms to enhance clinical reviews.
- Partnered with investigators to review clinical fraud cases.
- Supported SIU Pre-pay coding reviews.
- Mentored new coders, fostering their professional growth and development within the team.
- Delivered high-quality work consistently by adhering to established guidelines and maintaining strong attention to detail.
CLINCIAL INVESTIGATOR -Waste and Error
OPTUM
05.2015 - 03.2018
- Investigated and reviewed medical reimbursement policies, provided clinical and coding expertise.
- Interpreted state and federal mandates, applicable benefit language, medical and reimbursement policies, coding requirements, and relevant clinical information for claims with aberrant billing patterns.
- Identified aberrant billing patterns and trends, detected evidence of fraud, waste, or abuse, and recommended providers for review.
- Provided clinical support and expertise to other investigative and analytical areas.
- Participated in provider/client/network meetings.
- Served as a clinical resource to other areas within the clinical investigative team.
OUTPATIENT CODER
CONIFER HEALTH SOLUTIONS
12.2012 - 05.2015
- Assigned accurate ICD-9 CM, CPT, and HCPCS codes based on provider documentation for various outpatient encounters.
- Evaluated clinical documentation to determine medical necessity for nuclear scans, injections, and infusions.
- Demonstrated proficiency in working with specialized outpatient coding software systems, ensuring seamless integration of coded data into billing processes.
- Maintained a 95% accuracy rate.
MEDICAL CODING SPECIALIST
MEMORIAL HOSPITAL
02.2011 - 11.2012
- Responsible for coding inpatient and observation encounters in compliance with International Classification of Diseases, 9th revision (ICD-9 CM, and Current Procedural Terminology (CPT) guidelines.
- Conducted audits of Evaluation and Management services.
- Collaborated with healthcare providers to clarify ambiguous or incomplete documentation, resulting in more precise medical codes.
- Delivered educational sessions for physicians.
- Ensured timely submission of claims by diligently meeting deadlines for coding assignments, reducing the risk of delayed payments from insurers.
MEDICAL CODER
SPINE SURGERY ASSOCIATES
08.2006 - 01.2011
- Assigned accurate ICD-9, CPT, and HCPCS codes for spine surgeries, injections, hospital stays, and daily office visits.
- Collaborated with physicians to obtain necessary documentation, improving claim approval rates.
- Delivered educational sessions for physicians.
- Handled commercial and governmental provider appeals and conducted chart reviews.
- Attended coding and spine society seminars and conferences hosted by the North American Spine Society.
MEDICAL CODER/E/M AUDITOR
ERLANGER HOSPITAL
05.2010 - 11.2010
- Correctly coded and billed medical claims for for multi-specialty physician encounters and diagnostic services.
- Applied official coding conventions and rules from American Medical Association and Centers for Medicare and Medicaid Services to assign diagnostic codes.
- Ensured compliance with industry regulations and guidelines by staying up-to-date on the latest coding changes.
HOSPITAL CODER/CHARGE POSTER
DIAGNOSTIC CENTER
09.2005 - 08.2006
- Accurately assigned ICD-9 CM, CPT, and HCPCS codes for multi-specialty hospital surgeries and evaluation and management encounters.
- Review and address insurance coding denials following hospital charges
- Resourcefully used various coding books, procedure manuals, and on-line encoders.
MEDICAL CODER/ACCOUNT RECEIVABLES SPECIALIST
GASTROENTEROLOGY(GI) CONSULTANTS
11.2003 - 06.2005
- Accurately assigned ICD-9 and CPT codes for outpatient gastrointestinal procedures.
- Processed payments, verified insurance, managed accounts receivable, and handled charge entries.
- Managed recovery processes, pre-authorizations, and insurance coding denial follow-ups.
- Handled appeals for both commercial and governmental claims.
- Submitted claims electronically to insurance carriers.
Education
Bachelor's Degree - Healthcare Administration
King University
04.2017
Diploma - Medical Coding and Reimbursement
Brown College of Court Reporting And Medical Transcription
09.2002
Diploma - Information and Office Technology
Augusta Technical College
07.1994
Skills
- Attention to detail
- Independent Management
- Customer Oriented
- Adaptability and flexibility
- Strong verbal and written communication skills
- Establish and maintain positive relationships
- Microsoft Office (Word, Excel, PowerPoint), Pivot tables
- Teamwork and collaboration
- Proficient in ICD-9, CPT, and ICD-10 coding systems
- Proficient in various claims systems, including CPW, CSP FACETS, NICE, OXFORD, ISET, and ICES
- Critical thinking
Professional Associations
- American Academy of Professional Coders (AAPC), 2003-Current
- American Health Information Management Association (AHIMA), 2003-2004
- North American Spine Society (NASS), 2007-2011
Medical Coding Certifications
- Certified Professional Coder (CPC)
- Certified Outpatient Coder (COC)
- Certified Evaluation and Management Coder (CEMC)
Timeline
Coding Quality Analyst- Payment Network Integrity
Optum
12.2023 - Current
Postpay Coding -Special Investigations Unit (SIU)
OPTUM
03.2018 - 12.2023
CLINCIAL INVESTIGATOR -Waste and Error
OPTUM
05.2015 - 03.2018
OUTPATIENT CODER
CONIFER HEALTH SOLUTIONS
12.2012 - 05.2015
MEDICAL CODING SPECIALIST
MEMORIAL HOSPITAL
02.2011 - 11.2012
MEDICAL CODER/E/M AUDITOR
ERLANGER HOSPITAL
05.2010 - 11.2010
MEDICAL CODER
SPINE SURGERY ASSOCIATES
08.2006 - 01.2011
HOSPITAL CODER/CHARGE POSTER
DIAGNOSTIC CENTER
09.2005 - 08.2006
MEDICAL CODER/ACCOUNT RECEIVABLES SPECIALIST
GASTROENTEROLOGY(GI) CONSULTANTS
11.2003 - 06.2005
Bachelor's Degree - Healthcare Administration
King University
Diploma - Medical Coding and Reimbursement
Brown College of Court Reporting And Medical Transcription
Diploma - Information and Office Technology
Augusta Technical College
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