Tonya York

Performs validation reviews of DRG, APC, and Never Events for all lines of business. Coordinates rate adjustments and creates monthly/quarterly reports on records review, outcomes, trends, and savings.

Functioned independently to meet with providers and discuss Optum tools for improving Medicare Advantage care quality. Executed provider incentive programs, reviewed medical records for STAR opportunities, and developed provider-specific plans to improve HEDIS performance.

Reviewed medical records and arranged educational sessions with providers to improve documentation. Assigned ICD-10-CM codes mapping to risk adjustment models and analyzed claims data for risk adjustment accuracy.

Managed daily operations of a multi-specialty office including cardiology, gastroenterology, pain management, and family practice. Supervised staff, handled billing and A/R, and produced monthly billing reports.

Audited coders' performance on projects and contracts based on Coding Aid guidelines and 95/97 guidelines. Audited cardiology, emergency department, pediatric, and internal medicine coding.

Managed billing and coding for multiple clinics, overseeing accounts receivable on SCEIS and ensuring accurate coding and posting of Medicare and Medicaid payments. Served as compliance monitor for the billing section.

Audited physician documentation based on Medicare 95/97 guidelines and reviewed EOBS and remits for education. Audited surgery coding across various specialties and assisted with coding education and policy implementation.

Analyzed and coded diagnostic information in medical records based on client-specific guidelines. Ensured compliance with ICD-9/10 CM, APCs/DRG coding guidelines and third-party reimbursement policies.

Audited physicians based on 95 guidelines and coded urgent care specialty. Audited documentation using CPT, HCPCS, and ICD-10-CM codes, with knowledge of Medicare, Medicaid, and third-party regulations.

Supervised auditors' production and turnaround time, performed quality audits, and managed communication with coding staff and clients. Reviewed charts thoroughly and educated physicians on coding issues.

Audited coders and physicians documentation based on 95 and 97 guidelines, reviewed HCFAs and EOBs for education, and trained coders and physicians on deficiencies. Coded gastroenterology with accurate E/M, ICD-9-CM, and HCPCS codes.

Audited physician documentation based on 95 and 97 guidelines, educated providers on deficiencies, and audited E/M coding for various specialties. Worked with billing manager on coding and billing errors.

Assisted with calculating prices and estimates for procedures, performed coding for global and facility physician offices, and abstracted physician notes. Audited E/M codes for a cardiologist practice and tracked appealed denials.

Posted payments from third-party insurance companies, balanced accounts, and audited patient accounts with knowledge of CPT-4, HCPCS, and ICD-9-CM. Balanced payments using .835 files.

Analyzed physicians' and PAs' ICD-9-CM, CPT-4, and HCPCS codes, audited patient accounts, and posted payments. Managed denied and rejected claims and handled secondary/tertiary insurance using CMS-1500.

Registered patients for emergency room, radiology, EMS, and OR/SDS treatment. Screened insurance information for pre-certification, reviewed billing edits, and audited inpatient and observation bed counts.

Managed and enrolled individuals interested in Medicare Part D drug plan. Verified demographic and financial information and operated multiple Microsoft systems while respecting HIPAA.

Completed college courses in Health Informatics.

Earned a certificate in Medical Billing and Coding.

Studied Biology as a major and Chemistry as a minor.