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Yyyyyy x. yyyyyy

111 Passaic Ave. #A0000 xxxxxx xxxx , xxxx , xxxxx 00000



Medicare Hearing Officer & Adjudicator

Compliance Consultant ~ Medical Terminology ~ Insurance Regulations


Results-driven and versatile Medicare  Compliance SME seeking a new application of specialized skill set including Operational Support and Development, Training and Assessment Programs as well as comprehensive Data Analysis.  Eager to apply these skills to an organization in need of an extremely organized and experienced specialist who can streamline processes and increase productivity.

  CMS / HIPPA Knowledge

  Quality Assurance

  Accurate Coding (CPT/HCPCS)

  Medicare Law / Compliance

  SOP Development

  Billing Discrepancies

  Program Integrity

  Fraud & Abuse Investigations

  Medical Necessity Assessment


Qualifications Profile


Ø  Strong multi-tasking background with the ability to work independently on multiple projects simultaneously, including formulation of policies and procedures, organization development, training and development programs, meeting project deadlines, in-depth problem analysis and solutions, operational process implementation, as well as development and execution of strategies that ensure compliance of Medicare mandates.

Ø  Extensive knowledge and experience adjudicating provider billing/coding issues, blending well-honed communication skills with CPT/HCPCS/Medical/Pharma expertise.

Ø  Thorough knowledge of the proper use and application of medical terminology.

Ø  Liaised with myriad medical and professional consultants.

Ø  An adept writer and editor, integrating laws, regulations, and corporate policy to produce effective SOPs.


Transferrable Competencies


Ø  Effectively strategize with senior management to resolve complex issues related to billing, coding, and documentation. 

Ø  Excel in defining and implementing policies, procedures, and operational systems that boost productivity, efficiency and quality of operations.

Ø  Utilize extensive knowledge of administrative practices and data organization.

Ø  Consistently evolve the highest standard of delivery methodologies. 

Ø  Proven ability to adapt strong technical skills to diverse corporate needs.

Ø  Skilled at communicating cross-functionally to improve knowledge sharing between departmental lines.

Ø  Apply knowledge of various administrative functions and company protocols to support and advise management.

Ø  Embrace corporate culture and actively promote and lead company initiatives.

Ø  Frequently act as liaison between clients and company to pinpoint problems and seek solutions.

Ø  Technology savvy with knowledge of multiple software applications and platforms.  






Select Achievements  


Ø  Synthesized laws and regulations into readable paragraphs that ensured compliance with Federal/HIPAA directives and coding guidelines.

Ø  Developed parameters and conducted correspondence audits that improved quality and accuracy of the company s responses.

Ø  Examined an array of issues including overpayments, underpayments, coverage, and medical necessity, completing crucial projects within stringent time-frames.

Ø  Trained new Hearing Officers regarding the complexities and minutiae of appeals.



Professional Career Track


Medicare Hearing Officer / Adjudicator, Q²Administrators                             2006-Present                                                


Medicare Hearing Officer / Adjudicator, Pinnacle Medicare Services                2003-2006 


Medicare Hearing Officer / Adjudicator, Group Health Incorporated               1992-2006                                               


Medicare Hearing Officer / Adjudicator, United Health Care                                     1995-1999                                               


Earlier Experience


- Medicare Hearing Officer / Adjudicator, Adminastar 


- Medicare Hearing Officer / Adjudicator, Empire Blue Cross Blue Shield      



Academic Training


n M.S. C Physiology/Zoology, Rutgers University

n B.S. C  Biology, Fairleigh Dickinson University


















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