Karen Janesin
ksjanesin@yahoo.com
Objective: CPC-A since 2006 desiring an opportunity to gain experience as a coder either paid or unpaid in the Los Angeles area. I have 15+ years of experience in the healthcare which gives me a good foundation to be successful as a medical coder.
Skills Profile
Healthcare Professional with over 15 years experience in Health Insurance Plan and Hospital settings, including project data management, pre-certification, credentialing, knowledge of managed care HMO/PPO plans, ICD-9, CPT coding, auditing medical records, and CPC-A certification with the American Academy of Professional Coders (AAPC). Experience in Word, Excel, Access and Outlook.
Experience CIGNA HealthCare, Glendale, CA - January 1992 – Current
Business Project Senior Analyst:
Support activities relating to Health Plan provider integration processes and recruitment initiatives. Maintain data integrity in integration tracking system. Utilize Excel and Access databases to perform weekly/monthly production and ad hoc reports and assist with Disruption Analysis.
•Produce Excel and Access data reports for several state markets to assist in reporting the progress of all Health Plan Integration activities.
•Audit data and perform updates in tracking systems such as requesting automated updates or performing system updates manually.
•Assist with provider recruitment in researching competitor data and assisting with disruption analysis.
•Perform provider data comparisons utilizing Access databases and Excel spreadsheets.
Relationship Manager:
Act as market expert and primary resource in resolving complex provider data loading and integrity issues for several HMO/PPO Markets. Apply comprehension of numerous detailed policies/procedures and loading guidelines to daily work to ensure data integrity of HMO/PPO/TPV/FFS providers into the Provider Database System.
•Analyze detailed and complex data reports for submission of provider information for updates such as: fee schedule changes, tax id issues, billing information, and other provider specific data needing to be edited.
•Communicate and work effectively with internal and external matrix partners such as: Contractors, Market Leads, Regional Directors, Providers, and Customer Service in order to maintain accurate and valid provider data input which also requires critical thinking skills to resolve issues in a timely manner.
•Manage high volume data projects such as assisting in transitioning over 2,000 providers from individual contracts to group contracts in the provider database system.
Provider Relations Senior Associate:
Review MD/Practitioner applications in preparation for credentialing for several state markets applying numerous guidelines/procedures. Assist Competitive Intelligence with processing recruitment of providers accurately and quickly to assist with network expansion.
•Detailed review of provider credentialing applications which required daily communication with providers and staff for missing information such as: DEA, MD License, Malpractice Certificates, and other required information.
•Comprehensive review of contracts to ensure the proper fee schedules were given for geographic area and signatures were obtained on contracts and provider information accurately loaded into database.
•Respond to provider concerns and act as intermediary with the provider and credentialing departments to assist and respond to issues in a quick and effective manner.
•Train peers in other markets on the pre-credentialing process for various state markets.
Case Senior Associate
Perform daily quality reviews for Utilization Management Inpatient/Outpatient requests that require pre-certification in preparation for nurse or Medical Director Review. Maintain numerous department denial/approval letter templates requiring regulatory updates or revisions.
•Perform quality reviews requiring detailed research such as: verifying benefits, ICD.9/CPT coding, verify state & federal mandates, retrieve appropriate benefit coverage positions all within strict timelines.
•Manage tracking all transitional care requests (members new to CIGNA wishing to continue with their non-participating provider) for CA markets.
•Train co-workers and nursing staff on new letter retrieval process and letter generation in the pre-certification system.
•Provide as needed telephone coverage and assist with provider/member/customer inquiries and issuing pre-certification numbers. Notify determinations to members and providers which required excellent customer service skills handling case sensitive issues.
•Assist with several NCQA audits which required: locating key files, generating Excel reports, working with the Compliance Officer and UM Director which resulted in gaining NCQA accreditation.
Huntington Memorial Hospital, Pasadena, CA - February 1986 - December 1990
Incomplete Area Clerk II
Auditing of inpatient and outpatient medical records. Validate required information per compliance policies such as: Discharge Summaries, OP reports, History & Physicals, and required signatures were obtained for the medical record. Maintain and distribute weekly physician admitting suspension list.
Education Certified Professional Coder (CPC-A) 2006
American Academy of Professional Coders
Pasadena Community College Extended Learning – Certificate April 2006
Medical Insurance Billing and Coding Program
Baldwin Park Adult School- Certificate October 1989
Medical Transcribing & Terminology
Pasadena High School – Diploma June 1983
ksjanesin@yahoo.com
Objective: CPC-A since 2006 desiring an opportunity to gain experience as a coder either paid or unpaid in the Los Angeles area. I have 15+ years of experience in the healthcare which gives me a good foundation to be successful as a medical coder.
Skills Profile
Healthcare Professional with over 15 years experience in Health Insurance Plan and Hospital settings, including project data management, pre-certification, credentialing, knowledge of managed care HMO/PPO plans, ICD-9, CPT coding, auditing medical records, and CPC-A certification with the American Academy of Professional Coders (AAPC). Experience in Word, Excel, Access and Outlook.
Experience CIGNA HealthCare, Glendale, CA - January 1992 – Current
Business Project Senior Analyst:
Support activities relating to Health Plan provider integration processes and recruitment initiatives. Maintain data integrity in integration tracking system. Utilize Excel and Access databases to perform weekly/monthly production and ad hoc reports and assist with Disruption Analysis.
•Produce Excel and Access data reports for several state markets to assist in reporting the progress of all Health Plan Integration activities.
•Audit data and perform updates in tracking systems such as requesting automated updates or performing system updates manually.
•Assist with provider recruitment in researching competitor data and assisting with disruption analysis.
•Perform provider data comparisons utilizing Access databases and Excel spreadsheets.
Relationship Manager:
Act as market expert and primary resource in resolving complex provider data loading and integrity issues for several HMO/PPO Markets. Apply comprehension of numerous detailed policies/procedures and loading guidelines to daily work to ensure data integrity of HMO/PPO/TPV/FFS providers into the Provider Database System.
•Analyze detailed and complex data reports for submission of provider information for updates such as: fee schedule changes, tax id issues, billing information, and other provider specific data needing to be edited.
•Communicate and work effectively with internal and external matrix partners such as: Contractors, Market Leads, Regional Directors, Providers, and Customer Service in order to maintain accurate and valid provider data input which also requires critical thinking skills to resolve issues in a timely manner.
•Manage high volume data projects such as assisting in transitioning over 2,000 providers from individual contracts to group contracts in the provider database system.
Provider Relations Senior Associate:
Review MD/Practitioner applications in preparation for credentialing for several state markets applying numerous guidelines/procedures. Assist Competitive Intelligence with processing recruitment of providers accurately and quickly to assist with network expansion.
•Detailed review of provider credentialing applications which required daily communication with providers and staff for missing information such as: DEA, MD License, Malpractice Certificates, and other required information.
•Comprehensive review of contracts to ensure the proper fee schedules were given for geographic area and signatures were obtained on contracts and provider information accurately loaded into database.
•Respond to provider concerns and act as intermediary with the provider and credentialing departments to assist and respond to issues in a quick and effective manner.
•Train peers in other markets on the pre-credentialing process for various state markets.
Case Senior Associate
Perform daily quality reviews for Utilization Management Inpatient/Outpatient requests that require pre-certification in preparation for nurse or Medical Director Review. Maintain numerous department denial/approval letter templates requiring regulatory updates or revisions.
•Perform quality reviews requiring detailed research such as: verifying benefits, ICD.9/CPT coding, verify state & federal mandates, retrieve appropriate benefit coverage positions all within strict timelines.
•Manage tracking all transitional care requests (members new to CIGNA wishing to continue with their non-participating provider) for CA markets.
•Train co-workers and nursing staff on new letter retrieval process and letter generation in the pre-certification system.
•Provide as needed telephone coverage and assist with provider/member/customer inquiries and issuing pre-certification numbers. Notify determinations to members and providers which required excellent customer service skills handling case sensitive issues.
•Assist with several NCQA audits which required: locating key files, generating Excel reports, working with the Compliance Officer and UM Director which resulted in gaining NCQA accreditation.
Huntington Memorial Hospital, Pasadena, CA - February 1986 - December 1990
Incomplete Area Clerk II
Auditing of inpatient and outpatient medical records. Validate required information per compliance policies such as: Discharge Summaries, OP reports, History & Physicals, and required signatures were obtained for the medical record. Maintain and distribute weekly physician admitting suspension list.
Education Certified Professional Coder (CPC-A) 2006
American Academy of Professional Coders
Pasadena Community College Extended Learning – Certificate April 2006
Medical Insurance Billing and Coding Program
Baldwin Park Adult School- Certificate October 1989
Medical Transcribing & Terminology
Pasadena High School – Diploma June 1983