Raj kumar S
About Candidate
Detail-oriented Certified Professional Coder (CPC®) specializing in Evaluation & Management (E/M) coding, Medical Decision Making (MDM) table analysis, and CPT/HCPCS modifier application, with additional expertise in HCC risk adjustment and ICD-10-CM coding. Currently driving quality outcomes at Optum Healthcare while pursuing an MBA in Operations Management. Skilled in applying current CMS E/M guidelines, MDM-based level-of-service determination, National Correct Coding Initiative (NCCI) edits, and appropriate modifier usage (25, 59, 51, LT/RT, etc.) to ensure accurate code assignment, minimize denials, and support optimal healthcare reimbursement. Proven ability to thrive in high productivity environments, consistently maintaining a 96% quality and compliance score across multiple complex projects.
Location
Education
PASSED WITH FIRST CLASS DISTINCTION OF 90%
Work & Experience
• Performed accurate ICD-10-CM, CPT, and HCC coding, directly enhancing billing accuracy and supporting complex risk adjustment models. • Successfully executed high-volume risk adjustment workflows across major payer projects, including Aetna MRA, Anthem, and Harvard, consistently maintaining 96% quality accuracy alongside peak productivity. • Applied specialized risk adjustment methodologies to ensure precise, compliant, and granular documentation of patient specific chronic conditions and treatments. • Abstracted and analyzed complex clinical information to assign ICD-10 and PCS codes in strict accordance with official national guidelines. • Cross-referenced and confirmed diagnoses using pathology, histology, microbiology, and radiology reports to uphold superior clinical coding standards. • Designed and implemented a peer-review system to proactively capture coding discrepancies and systematically reduce error rates across the team. • Conducted routine internal audits of coding accuracy, identified compliance gaps, implemented corrective actions, and provided targeted coaching to team members on best practices. • Streamlined daily coding workflows by leveraging automation tools, significantly reducing manual data-entry errors and increasing overall case throughput. • Monitored industry regulation updates (AHA Coding Clinic, CMS), rapidly adapting internal procedures to maintain absolute legal and HIPAA compliance. • Participated in ongoing advanced coding workshops and seminars to stay ahead of evolving ICD-10-CM, CPT, and HCC guidelines.
Portfolio
