Tracey L Zortorres, CPC,CRC,CPB
Pueblo,CO
Summary
Accomplished healthcare professional with a proven track record in HCC risk adjustment coding, regulatory compliance, ICD-10-CM, CPT, HCPCs coding guidelines. Successfully identified coding trends and conducted thorough audits to ensure precise documentation for Medicare Advantage. Leveraged data analysis to significantly enhance performance metrics. Expert in claims analysis, achieving notable reductions in claims denials and driving process improvements. Demonstrated success in obtaining pre-certifications, verifying insurance eligibility, and guiding providers on accurate coding practices.
Overview
24
24
years of professional experience
1
1
Certification
Work History
Risk Adjustment Educator
Alphine Physicians Health Partners
01.2024 - Current
- Educated and advised healthcare providers and practice staff on all aspects of HCC Risk Adjustment coding, regulatory and compliance requirements, ICD-10-CM official coding guidelines, proper documentation accuracy for Medicare Advantage, and revenue enhancement opportunities.
- Collaborated with other PHP departments and several Medicare Advantage health plans in developing plans and materials that support education and system changes to meet practice and IPA revenue goals.
- Identify potential data flow obstacles within assigned practices and work with practice staff to develop action plans to assist practices in overcoming obstacles to maximize reimbursement.
- Identify and solve issues with vendors (billing companies, clearinghouse) to remove obstacles that prevent maximum code extraction and submission.
- Audited 40 plus charts per day and query providers to address documentation reassessment opportunities and to prompt higher accuracy and/or specificity.
- Collaborated weekly with managers and team members to implement and/or change workflow processes for new and existing practices joining PHP platform.
- Familiar with various Electronic Health Record (HER) such as Elations, E-Clinical Works (eCW), Athena, Practice Fusion, NexGen, and Cerner.
- Improved revenue cycle management by accurately assigning HCC codes to maximize reimbursement potential.
Risk Adjustment Provider Educator
Cigna Healthcare
10.2020 - 12.2023
- Educated providers on all aspects of HCC Risk adjustment coding, regulatory and compliance requirements, ICD-10-CM official coding guidelines, and proper documentation accuracy for Medicare Advantage patient population.
- Identified coding trends and documentation patterns by reviewing data retrieved from patient's medical records and claims audits.
- Evaluated documentation to ensure that diagnosis coding is supported with and meets specificity requirements to support clinical indicators, HEDIS & STARs quality measures.
- Reviewed provider's performance metrics, by compiling data using tableau and pivot tables to present solutions regarding trends or patterns noticed in provider coding and documentation. Tailored education to providers accordingly.
- Conduct provider training and group education sessions on proper coding and documentation practices for physicians and staff consistent with industry standards and in compliance with official coding guidelines.
- Created and analyzed data on low performing providers and strategically implemented a plan to increased performance metrics and maximize reimbursement.
- Utilized encoder pro, CMS online mapping tool, and other coding resources to determine the appropriate ICD-10-CM diagnosis codes mapped to HCCs.
- Trained providers and staff on the Arcadia platform for online submission of Cigna’s annual wellness forms.
- Conduct provider training and group education sessions on proper coding and documentation practices for physicians and staff consistent with industry standards and in compliance with official coding guidelines.
- Familiar with various Electronic Health Record (EHR) such as E-Clinical Works (ECW), Athena, Practice Fusion, NexGen, Elation, and Cerner.
Claims Analyst - Coding and Reimbursement
Cigna Healthcare
10.2020 - 02.2023
- Reviewed and audit accuracy of ICD 10-CM, CPT, and HCPCS coding for approved Radiation Therapy authorization treatment plans for 40+ health plans.
- Analyzes clinical documentation provided to support medical necessity and reviews patient history, when necessary, that may affect audit for a new treatment course.
- Provided education to onsite Medical Directors on correct coding guidelines for Radiation Oncology cases.
- Reviews applicable federal, state, and commercial policies and regulations governing healthcare reimbursement.
- Collaborates with over 30 plus team members regarding education to propel correct coding payment rules, bundling rules, substitution rules, and certain claim policies and procedures.
- Reviews and analyzes claims issues related to identifying possible claim rules errors, correct coding rules, system configuration errors, inconsistencies, anomalies, abnormal patterns, and other indicators of suspected fraud, waste, or abuse.
- Slashed claims denials by partnering with denial team to assist with getting denied claims paid within 30-day timeframe.
- Collaborated with management, oncology leadership, and team members on process improvement and development.
- Researched claims and incident information to deliver solutions and resolve problems.
Billing Pre-Certification Coordinator
HCA Tristar Division
04.2019 - 10.2020
- Obtained approval from insurance companies and third-party vendors, for physician and facility services that require referral, pre-certification, prior authorization or utilization review; verify insurance eligibility and benefits to determine patient eligibility and liability.
- Assigned correct CPT code, ICD 10-CM, and HCPCS Level II code if required to every patient being treated for radiation oncology service to ensure patient charged correctly for services and proper claim filing.
- Educated physicians and office staff on proper documentation necessary to support medical necessity, authorization approval, and correct filing of insurance claims
- Worked closely with team members in billing and revenue integrity to resolved denied claims
- Submitted appeals in a timely manner using department resources with appropriate documentation.
- Collaborated with team leader and peers on process improvement and development.
Accounts Receivable Representative
AT&T
11.2000 - 04.2019
- Managed monthly, quarterly, and year-end close processes of accounts receivable, including reports, schedules, revenue, and other ad hoc information requested by management, audit or other departments.
- Succeeded in handling incoming telephone contacts with customers in collecting company revenue, records, data, and notations.
- Negotiated payment arrangements with customers to establish timely receipt of payments.
- Delivered exceptional customer service on collection calls and maintained calm and professional demeanor.
- Sparked negotiations and extension of credit in alignment with company goals for revenue protection, achieving over revenue growth year-over-year.
- Consistently identified and resolved accounts receivable related issues.
- Served as Interim Resolution Manager, de-escalating complex situations and offered optimized solutions.
Education
Certificate - Medical Coding & Billing
Jefferson State Community College
Birmingham, ALBachelor of Business Administration -
Faulkner University
Montgomery, ALSkills
- Medical Claims Processing & Resolution
- HIPAA Regulations
- ICD-10-CM
- CPT, HCPCS
- Medical Terminology & Clinical Knowledge
- HCC Risk Adjustment Coding
- Audits & Analysis of Medical Coding
- Training & Education
- Team Leadership & Guidance
- Business Process Improvement
- Team Collaboration & Leadership
- CMS Rules & Regulations
- Workflow Management
- Clinical Documentation
Certification
- Certified Risk Adjustment Coder (CRC), American Academy of Professional Coders (AAPC), 2022
- Certified Professional Biller (CPB), American Academy of Professional Coders (AAPC), 2020
- Certified Professional Coder (CPC), American Academy of Professional Coders (AAPC), 2019
Timeline
Risk Adjustment Educator
Alphine Physicians Health Partners
01.2024 - Current
Claims Analyst - Coding and Reimbursement
Cigna Healthcare
10.2020 - 02.2023
Risk Adjustment Provider Educator
Cigna Healthcare
10.2020 - 12.2023
Billing Pre-Certification Coordinator
HCA Tristar Division
04.2019 - 10.2020
Accounts Receivable Representative
AT&T
11.2000 - 04.2019
Certificate - Medical Coding & Billing
Jefferson State Community College
Bachelor of Business Administration -
Faulkner University
- Certified Risk Adjustment Coder (CRC), American Academy of Professional Coders (AAPC), 2022
- Certified Professional Biller (CPB), American Academy of Professional Coders (AAPC), 2020
- Certified Professional Coder (CPC), American Academy of Professional Coders (AAPC), 2019
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