Director of the HIM and Medical Transcription Departments
2008 to Present
600-bed, level 1 trauma center community-based facility with full multi-site service for acute and sub-acute care including emergency services, renal dialysis, inpatient surgical and medical services, outreach clinic facilities, acute psychiatric services, heart and cancer centers, ambulatory services, sub-acute rehabilitation, and drug detoxification.
Director of the HIM and Medical Transcription Departments, 2008 - present
Accountable for 130 FTE's and all assembly, analysis, filing, coding, correspondence, release of information, scanning, indexing, QA and transcription functions.
• Designed, built and led the implementation of the HIM Epic electronic health record.
• Established and led the corporate scanning department.
• Successfully redesigned /restructured the coding service line.
• Developed departmental policies and procedures in accordance with HFAP requirements.
• Successfully planned/coordinated the installation of a new back-end speech recognition system.
• Successfully implemented coding work flows which improved efficiencies and reduced DNFB by 34 million dollars.
• Successfully developed/implemented a chart completion/suspension policy / procedure which reduced medical record delinquencies from 104% to 9% within 4 months.
• Successfully planned and coordinated the install of the 3M Encoder interfaced to the mainframe system.
• Successfully performed facility impact assessment and coordinated the plan to transition from ICD-9 to ICD-10 coding.
• Served as a core member of the RAC, Crimson, Osteopathic Concepts, trauma merge and UR/HIM Committees.
• Successfully led/implemented PI initiative for CVOR, Cath Lab and EP Lab recovering 8 million dollars in lost revenue.
• Successfully coordinated construction project for.
• Developed operational and capital budget.
• Successfully education physicians and staff on documentation guidelines.
• Successfully perform coding audits.
• Successfully developed/implemented the physician allocation table.
2008 to 2008
200-bed community hospital including medical and surgical service lines.
2007 to 2008
Designed and developed the coding department including selection and implementation of the 3M encoder, training of the coding staff and physicians.
• Successfully built the coding department of the ground up.
• Successfully implemented 3M and Meditech.
• Acted as physician and staff educator on documentation guidelines, medical necessity and organizational policies and procedures.
• Developed policies and procedures for tracking physician delinquency rates, monitoring DNFB, diagnosis and procedure coding, encoder utilization, DRG assignment, POA reporting and productivity requirements.
• Acted as ABN manager and consultant for the billing department.
• Performed chart audits.
• Functioned as inpatient and outpatient coder as needed.
Physician Coding Compliance Manager
2004 to 2007
227-bed community hospital including medical, surgical, rehabilitation, Obstetrics and emergency service lines.
Physician Coding Compliance Manager, 2004-2007
Accountable for 5 coders and roughly 125 employed and non-employed providers. Managed professional coding service line and physician compliance.
• Managed the professional services coding department.
• Performed CPT, E&M and ICD-9 coding for the emergency department.
• Established compliance program for the professional corporation including auditing of multiple specialties.
• Performed physician orientation and education on the documentation guidelines.
• Acted as the principle physician trainer for the IBEX implementation.
• Developed the hospital's audit plan in compliance with the OIG work plan.
• Acted as an active member of the process improvement committee.
• Acted as compliance officer for the organization.
2002 to 2004
Oversight of clinical and clerical operations.
• Supervised and trained staff.
• Negotiated rates and terms of insurance contracts.
• Performed coding and billing to include E&M leveling, CPT and ICD-9 codes.
• Incorporated in-house billing.
• Led Meditech computer conversion.
• Instrumental in new facility planning.
• Performed insurance precertification and verification.
• Maintained OSHA, CLIA and HIPAA compliance.
• Responsible for collection activity.
• Developed corporation's internal policies and procedures.
1999 to 2002
Performed CPT, E&M and ICD-9 coding
1995 to 2001
• Experienced leader for acute care, community and rural hospitals serving release of information, facility and professional coding, transcription, assembly &analysis, scanning, chart correction and physician monitoring services.
• Proven success in building collaborative relationships with hospital department heads and implementing programs that successfully engage board, executive and physicians leaders in support of process improvement initiatives resulting in significant and sustained reductions in the DNFB.
• Extensive expertise with physician documentation education.
• Extensive expertise in regulatory and compliance standards.
• Expertise in identifying cost effective staffing models, operating and benchmarking systems to support effective HIM operations.
• Expertise in clinical and professional coding with certification as AHIMA ICD-10 trainer.
Led 3 EMR/computer conversions: Epic, IBEX, Meditech, 3M
Epic, Quantim, 3M, Meditech, Medic, Advantx, Medisoft, Quadramed's Affinity, Nuance (eScription), MicroMD, Code Correct, CraneWare, Logician, Quadex, IBEX, ValcoViewer