Billing-revenue cycle healthcare
John K. McCauley
3214 Deerchase Wynd, Durham, NC 27712
(919) 382-8190 (H)
(919) 601-7909 (C)
Summary: I am a highly skilled and experienced healthcare administrator with over 20 years in the field. My experience includes every aspect of the revenue cycle, from insurance verification to coding, charge capture, billing and account follow up. This includes hands on experience as well as supervisory/management in many of these areas. I will bring all this experience plus an unparalleled work ethic that will prove to be an asset to any company looking for the best they can get.
Core Competencies: Proficient in use of various practice management coding and billing software systems, including Misys Vision, White Plume, IDX, MDeverywhere, eBrowser, Netscape, Siemens SMS, Encoder Pro,Allscripts, NextGen,and Navicure, as well as MS Excel, Word. I also have taken additional workshops, seminars and training classes pertaining to healthcare, including Medicare, Medicaid, BCBS billing/coding regulations, ICD-10 as well as accounting, finance and managing multiple priorities, among others.
Collins & Franklin Plastic Surgery, LLP September 2015-present
Revenue Cycle Consultant
- Managing AR to include denials review, account reconciliation including coding corrections, charge abstraction based on documentation and collections. Identify systems errors/ issues and make necessary corrective action recommendations within PM and clearinghouse to the appropriate parties. Assist in transition to ICD-10 coding implementation.
Cape Fear Orthopaedic Clinic, Fayetteville, NC June -September 2015
- Oversee, coordinate and direct the activities of the Central Billing Office and other key aspects associated with the revenue cycle of the practice, including charge capture, coding, billing and denials management, as well as AR oversight and management. Direct and coordinate the hiring and activities of the staff. Serve as the main point of contact for billing and insurance matters for all services provided by the practice. Assist and serve as a resource in the establishment and review of records for coding and compliance with internal and external guidelines. Establish goals and benchmarks for the performance of the billing and collections department. Review and refine reports and reporting of key information related to the billing and collection function. Provide periodic information and reports to providers and management on billing and collection matters As required, r represent Cape Fear and all departments in claims disputes with payers. Periodically prepare reports related to monthly, quarterly and year-end needs.
Sterling Medical-US Air Force, Hampton, VA August – October, 2014
Ambulatory Visit Procedure Coder (contract)
- Responsibilities include coding all ambulatory/same day surgical procedures as well as revenue integrity/ compliance review.
Raleigh Orthopaedic Clinic, Garner, NC 2011 – 2014
Manager, Central Billing Office
- Oversee, coordinate and direct the activities of the Central Billing Office and other key aspects associated with the revenue cycle of the practice, including the Medical Records Department for 5 outpatient clinics, 2 physical therapy clinics, 2 athletic performance centers and associated DME and Orthotics and Prosthetics business lines. Direct and coordinate the hiring and activities of the staff. Serve as the main point of contact for billing and insurance matters for all services provided by the practice. Assist and serve as a resource in the establishment and review of records for coding and compliance with internal and external guidelines. Establish goals and benchmarks for the performance of the billing and collections department. Complete the monthly Revenue Balancing report Review and refine reports and reporting of key information related to the billing and collection function. Provide periodic information and reports to providers and management on billing and collection matters. Review and participate in managed care negotiations. As required, represent ROC and all departments in claims disputes with payers. Periodically prepare reports related to month, quarter and year-end needs.
- Reduced A/R greater than 150 days from 21% as of 12/2010, to 1% as of 12/2013.
- Increased A/R less than 90 days old to 90% as of 12/2013, from 71% as of 12/2010.
- Reduced DRO from 50+ days to 37.
- Denial rate is now 9.47%.
Duke University Health System, Durham, NC 1999 – 2011
Medical Coder, Coding Operations 2010 – 2011
- Coordinate/review the work of subordinate employees and assist with the training and continuing education programs. Code medical records utilizing ICD-9-CM and CPT-4 coding conventions. Review the medical record to assure specificity of diagnoses, procedures and appropriate/optimal reimbursement for hospital and/or professional charges. Abstract information from medical records following established methods and procedures.
- Consult with and educate physicians on coding practices and conventions in order to provide detailed coding information. Communicate with nursing and ancillary services personnel for needed documentation for accurate coding.
(On Medical Leave from 1/2008 – 6/2010)
Supervisor, Coding and Charge Capture 2005-2008
- Team leader for coding/billing section of conversion to MDeverywhere, resulting in reduction of missed charges with subsequent increase in revenue.
- Wrote policies and procedures resulting in coding quality audits with monthly accuracy ratings of 97-100% as well as procedural/operational audits of 100%.
- Updated billing system edits, reducing a number of coding/billing denials by 20%.
Manage all coding and billing processes for professional services at 3 hospital/surgery centers, including auditing of medical records and obtaining prior authorizations. This includes writing policy & procedures, physician education, hiring staff. The services responsible for include the Hospitalists, ICU, other inpatient services, OB-Gyn, Ophthalmology, Interventional Radiology, surgery, palliative care, Special Cardiology Surgery, Allergy & Airway and Cardiac Cath. Responsible for review and analysis of monthly financial reports for various services: research coding/billing deficiencies and implement corrective actions. Audit coding/documentation of physician/coding staff. Perform ICD/CPT surgical coding. Interact daily with senior management, physician enrollment department, physicians, and payors. Maintain and verify records of filing procedures/requirements for various insurance carriers, i.e., Medicare, Medicaid, BCBS, and Workers Compensation. Supervision of staff up to 7.
Reimbursement Specialist 2004-2005
- Leader for special projects to decrease backlogs in coding and billing. Cleaned up $3,000,000 in charges that were held for coding edits/errors for the Ophthalmology Department, coding ED consults for Orthopedics, Otolaryngology and Plastics Divisions.
- Served as the surgical coder for Ophthalmology and the Ambulatory Surgery Center at Duke.
Practice Specialist-ENT/Plastics/Oral Surgery/Orthopaedics 2002-2004
- Team leader on project to implement MDeverywhere for Emergency Department consults resulting in over $1million in annual revenue.
- Member of co-surgery billing improvement team which resulted in proper coding and documentation leading to a 25% increase in revenue for co-surgery cases.
- Identified $92,000 account denied for no authorization. We had prior authorization but procedure occurred outside the authorization dates. Contacted carrier, they agreed to extend the authorization period which resulted in a $65,000 payment.
Identified revenue enhancement opportunities and implement solutions toward maximizing revenue. Provide essential feedback to physicians/providers regarding coding and denials. Work coding denials file, making appropriate corrections and re-file claims. Work coding/pre-billing edit file, making necessary corrections and/or adjustments for filing claims. Interact with physicians, clinical personnel, coders, patients and insurance carriers on a daily basis. Train other Practice Specialists in sorting and working edits/coding denials files. Chairperson of several management projects: ED Consult Charge Capture, Co-surgery Billing Process Improvements. Member of Perioperative Improvement Team. Practice Specialist lead in Coding Denial Revenue Enhancement Team.
Reimbursement Analyst II – Professional Billing 2001-2002
- Initiated coding/billing corrections or adjustments on $3 million in denied charges for Neurology Department resulting in collection of $1 million+ in reimbursement.
Resolved pre-billing edits. Decrease/eliminate coding related denials based on review of charges prior to claim submission. Ensure proper/ timely filing of charges by reviewing documentation related to edited charges. Remain current on Medicare Teaching Physicians Guidelines, CPT/ICD coding, as well as other applicable guidelines/regulations. Provide feedback to appropriate personnel on coding and documentation processes. Provided enhancement of processes through research and analysis of guidelines and systems, including coding recommendations, addition/elimination of edits, identify training opportunities. Work on special coding reimbursement projects as requested.
Reimbursement Analyst II – Reimbursement Department 1999-2001
- Resolved coding/billing edits and denials; ensure appropriate processing of charges by compiling and reviewing documentation related to denied/edited charges. Remain up to date on Medicare Teaching Physician Guidelines, E/M coding guidelines, and other applicable guidelines. Provide feedback to the appropriate personnel in coding and documentation process. Monitor charges in coding/billing work files. Decrease/eliminate coding related denials based on review findings. Provide enhancement of systems and processes through research and analysis of appropriate guidelines: coding recommendations, add/eliminate edits, identify training opportunities and provide feedback to appropriate persons. Develop written policies and procedures with other relevant personnel as necessary.
Durham Regional Hospital, Durham, NC 1999
Patient Accounting Manager
- Set up team concept. Each team responsible for specified insurance carriers. This allowed for better understanding/knowledge of carrier requirements leading to increased reimbursement and lowering DRO’s by 20%.
- Performs supervisory work in the Patient Accounting area to ensure all operational activities are performed efficiently and accurately by the staff in a timely manner. Responsible for establishing and maintaining overall policy and procedures and coordinating operations with other hospital units and medical staff. Interview, select, hire, train, counsel and discipline employees. Responsible for ensuring collection procedures are followed, insurance claims are filed and associated records are maintained. Work closely with all areas of Patient Financial Services, such as Billing, Cashiering and Follow-up Collections, to ensure patient accounts are processed timely and accurately. Review department performance in relation to established goals. Implement changes to effect continual improvement in services provided, and assure compliance with regulatory and legal requirements. Supervised staff of 12.
Previous relevant work history
Reimbursement Analyst II – Reimbursement Department, 1998-1999 – Duke University Medical Center
Coding Specialist 1997-1998 – UNC Physicians and Associates
Healthcare Business Resources, Durham, NC- 1990-1997 Senior Operations Analyst. Medical billing company for ED’s in 26 states.
NaRe (North American Reassurance Company), New York, NY-1985-1989- Senior Claims Analyst
New York Life Insurance Company, New York, NY 1980-1985- Senior Compensation Analyst
B.A., Sociology, Cortland State University
Accreditations and Professional Associations
Certified Professional Coder (CPC)
National Legislative Chair – AOA 9/04 – 9/07
Member Communications Committee AOA 9/04 – 12/07
AOA Member 12/02 – 9/08
MGMA 2012 – present
Triangle Managers Association 2012 - present