# Gayla Wykes, CPC Resume



## gwykes@austin.rr.com (Jun 1, 2018)

GAYLA WYKES, CPC
7205 Navajo Pass
Volente, TX. 78641
(512) 567-4191 (cell)
Certified Professional Coder -  accredited Body of A.A.P.C.; ICD-10 Proficient
Email: gwykes@austin.rr.com
U.S. Work Eligibility: U.S. Citizen

OBJECTIVE: To find an employer that appreciates hard work, an eye for detail and offers
opportunities for growth and knowledge expansion. I am a very motivated and dedicated employee
which ensures effective performance. I am a self-starter with the ability to work independently; yet effectively contributes to a team.  


CAREER EXPERIENCE:

2-19-18 to 5-4-18            Clinical Coding Specialist - EMR Reviewer (C.P.C.)
Blue Cross Blue Shield      9442 N. Capital of Texas Highway  Suite 500
[HEDIS Project]                Austin, TX. 78759
(Contract-Temp. position)  

EMR [EHR] review to ensure a positive outcome for the Provider and the Carrier during the HEDIS quality review. Abstraction from the EMR or Medical Record; logged the required data elements and key measure components for compliance per CMS' annual reviews.



4-18-17 to 10-27-17             Certified Professional Clinical Coding Analyst (CPC)	
9-27-16 to 1-30-17               12357 Riata Trace Parkway
Accenture/Medicaid            Austin, TX. 78727           
(Contract position)                          

Provided support along with policy interpretation to Medical Services programs; Performed research and coverage determinations; Researched and identified best practices and evidence based research studies in support of coverage determinations; Consulted with Industry resources, regulatory authorities, Insurance Carriers, and Health Plan Administrators to help ensure the development and maintenance of medical services guidelines; Presented research findings; Extensive CPT, HCPC, Modifier(s), and ICD-10 knowledge/application and research; N.C.C.I. Application(s)/Edits; MUE's;  Medical terminology and [limited] Clinical application.



10-27-15 to 9-23-16           Coding Auditor [Remote position]
MediGain, LLC                   2800 Dallas Parkway
                                               Plano, TX. 75093

Performed prospective and retrospective Audits of Medical Providers claims, site of In-Office and in                  
the Outpatient setting; Reviewed denied/un-paid claims [appeals]; Validation that documentation adhered to the Correct Coding Policy guidelines and Documentation requirements; Ensured that correct codes are [were] submitted on the Medical Bill; Review/knowledge of various CPT/HCPC Code sets and Modifiers, along with ICD-9 and -10 codes; abundant EHR review; Medical terminology; N.C.C.I. Application/Edits; MUE's; Medical terminology; interpretation and application of LCD's [Local Coverage Determinations]; Auditor skill set allowed for independent judgment. 



11-3-14 to 10-21-15         Workers' Compensation Specialist [Pain Management]
Advanced Pain Care        2000  South  I-H 35 
                                              Round Rock, TX. 78664

Performed verification/validation of all Workers' Compensation patients prior to appointment
scheduling; Charge Entry/Coding; interpretation and application of LCD's [Local Coverage Determinations]; Entering Insurance information, Extensive customer service [outreach] 
with Insurance Adjusters and patients; Performed/requested Pre-authorization(s) of procedures/treatments 
as identified on D.W.C.'s pre-authorization list prior to the performed procedure(s); O.D.G., Working knowledge of Insurance forms and disputes; EOB review; Appeals; CPT & ICD-9/10, Modifiers, and HCPC codes; migration of data into EHR system; Abundant EHR review/logging.



04-26-12 to 2-7-14                Medical Review Coordinator (Analyst) * (Remote position for 6 months) *
FirstCare Health Plans        12940 Research Blvd.
                                                  Austin TX. 78750

Performed reviews/audits of Provider's medical claims to ensure accurate coding
and compliance in accordance with Medicare, Medicaid, and C.H.I.P. payment policies and billing
methodologies. Daily review of Physicians' and Facilities' documentation to identify and maximize
Insurance Carriers' [and Governmental] savings. Knowledge and daily application of EncoderPro,
{Optum} CMS, and TMHP websites. External and Internal customer service and problem solving.
Retrospective review of claims to identify any overpayment(s) and/or fraudulent billing practice(s).
Proficiency with Microsoft Excel, Word, and limited Access. Ensured CPT/ICD-9 and Modifier accuracy; Extensive medical terminology knowledge; LCD application(s); N.C.C.I. Application(s)/Edits-MUE's; Use of CMS 1500 and UB-04 claim forms; Auditor skill set allowed for independent judgment. 



06-06-11 to 04-13-12               Medical Bill Auditor (Worker's Compensation)
Forte' Managed Care              7600 Chevy Chase Dr. #200
                                                      Austin TX 78752

Applied DWC fee guidelines and Medicare policies to medical claims for various
insurance carriers to include Professional fees, Lab & Radiology, Hospitals, DME, and Pharmacy bills.
Worked denial and un-paid claims, Knowledge of workers' compensation forms and reports,
ICD-9 & CPT coding; Hospital Billing; Medicare guidelines and payment policies. Auditor skill set 
allowed for independent judgment. Extensive medical terminology knowledge; N.C.C.I. Application/Edits; Use of CMS 1500 and UB-04 claim forms; Claim Processing/Adjudication familiarity; Quality Assurance.



05-14-07 to 8-26-10                          Medical Fee Dispute Resolution Officer (M.D.R.)
Texas Department of Insurance      7551 Metro Center Dr. 
                                                               Austin, TX. 78744

Issued formal Decisions and Orders to system participants within the Workers'
Compensation system. Audited/Applied State Rules and Laws to medical claims from Providers,
Carriers, and Injured Workers. Ensured that insurance carriers and medical providers adhered to Texas fee
schedule statutes and regulations; compliance monitoring. Claims analyzed per Medicare and D.W.C.
guidelines.-Performance of violation referrals for non-compliant system participants. {System Monitoring
Oversight} Last informal procedure prior to filing hearing in District Court. Application of independent
judgment and minimal supervision. P.P.O./Certified Network claims knowledge. Exceptional
E.O.B./Appeal knowledge. Application of current coding standards in accordance with the AMA;
Demonstrated proficiency in conflict resolution.



09-23-00 to 05-01-07             Medical Bill Audit Consultant (Auditor)
CorVel Corporation               3721 Executive Center Dr.
                                                    Austin, TX 78731

Applied TWCC/DWC fee guidelines to medical claims for various insurance
carriers to include Professional fees, Lab & Radiology, Hospitals, DME, and Pharmacy bills; quality
assurance; extensive customer service with Providers and Insurance Adjusters; abundant knowledge of
workers' compensation forms and reports, ICD-9 & CPT coding; Hospital Billing;. Medicare guidelines
and payment policy knowledge, Provider's appeals/reconsiderations. Application of industry expertise.
Application of independent judgment and minimal supervision. Exceptional E.O.B./Appeal knowledge.
An abundance of industry expertise helped me to ensure compliant claims processing. I previously
held a team leader/supervisor position. Extensive medical terminology application.


RELATED SKILLS:
• Strong organizational and detail-oriented skillset
• Self-starter/Multi-tasker
• Well regarded for interpersonal, written and oral communication skills
• Effectively handles multiple tasks simultaneously
• Demonstrated ability to acquire and apply knowledge rapidly
• Independent; works with minimal supervision, yet contributes to a team


EDUCATION: 
American Academy of Professional Coders (AAPC):  Certified Professional Coder (C.P.C. - # 01352870)
Adjuster's Training Solutions: All-Lines Adjusters License (previously held)
Leonard's Training Program: 17-03 Adjusters License (previously held)
Austin Community College: Emergency Medical Technician Cert./EMT-B (previously held)
Completion of 'Business Writing Levels I and II' as offered through T.D.I.*
Completion of 'Successful Time Management' as offered through T.D.I. *


REFERENCES: 
Margie Perez  (512) 202-5392
Crissy Garcia (512) 371-8400
Leticia Shearin (512) 921-6778
Judy Klecka (512) 818-7318
Martha Luevano (512) 680-9271
Margaret Ojeda (512) 804-4000
Marta Sadowski (512) 809-9783


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