Areas of Expertise
- Assessment & Optimization
- Health Data/CDM Analytics
- Health Plan Auditing
- Provider Claims Auditing
- Revenue Cycle Management
- Revenue Integrity
- Risk Adjustment Data Validation
- BS Boise State University
- 1 Year with Firm
- 14 Years of Relevant Experience
Nicole King, RHIT, CHC brings B. Riley extensive experience in health plan auditing, including both Initial Validation Audit (IVA) and Risk Adjustment Data Validation (RADV), revenue integrity optimization, health data/CDM analytics and revenue cycle management. She is an established expert at analyzing revenue capture processes for opportunities, quantifying financial impacts and implementing innovation solutions to achieve superior outcomes. She has extensive knowledge of standard clinical procedures and their impact to efficient and optimal revenue cycle performance. Her specialties include operational process improvement, internal audit and risk management, workflow assessment and redesign, and the ability to use data analytics to enhance revenue capture processes while improving operational efficiency.
Ms. King's experience includes:
- Served in a leadership role for the build and design of a HHS operated Risk Adjustment Data Validation Audit program serving some of the largest health plans in the U.S.
- Provided Senior Official oversight of Initial Validation Audit results submission to CMS
- Played a primary role in the design, build and validation of audit framework.
- Assisted in the development of software tools to automate the audit process.
- Provided education to client facing stakeholders as well as internal auditors as CMS released updates to audit parameters and related regulations. Managed client expectations, data submissions, and project timelines and milestones.
- Served as Director of Revenue Integrity, Sr. Manager Charge Capture, and CDM Analyst for one of Truven's Top 15 Health Systems in the nation.
- Provided revenue integrity oversight for 7 hospitals; 1,000 staffed beds; 150+ clinics; 1,300+ physicians.
- Developed charge capture policies and procedures for 1200 service line departments with annual revenues of $1.8 billion.
- Implemented revenue integrity audits and concurrent edit processes to improve revenue capture timeliness, quality, and reduce missed revenue.
- Assisted with CDM management and compliance initiatives to include CDM set up, oversight, and updates.
- Collaborated with health system leaders to establish revenue capture accountability and performance monitoring.
- Assisted with the design of a Revenue Cycle Analytics Tool as part of Revenue Readiness support strategy in preparation for EMR implementation.
- Designed and implemented a revenue integrity training and education program for health system leadership to improve knowledge and compliance with department revenue capture procedures.
- Implemented a remote coding program to improve coder retention and reduce operational costs within revenue cycle.
- Optimized Epic implementation to include work queue structure redesign and charge router rule configuration.
- Managed a team of 35 coders, all specifically trained in Revenue Integrity.
- Served as Data Analyst and Clinical Data Abstractor for a Level II Trauma Center, requiring the highest standards for chest pain, stroke, orthopedic, general surgery, and emergency care.
- Developed and implemented activities and tools to promote quality care and core measure compliance.
- Investigate clinical processes to determine problem areas and identify opportunities for improvement.
- Assure compliance with data collection specifications and submission procedures set forth by CMS.
- Perform medical record reviews to collect and report data as part of CMS Pay for Performance Quality Initiative and Joint Commission standards.
- Facilitate risk management activities associated with the Peer Review process.
- Serve as Midas Database Administrator to ensure accurate management of risk event reporting and follow up.
- Served as Quality Specialist for an ambulatory clinic network with over 100 providers located throughout 18 regional clinics.
- Designed and implemented a chart audit program to facilitate reporting of quality measures as part of the CMS Pay for Performance Program.
- Participated in the design and implementation of an electronic medical record system.
- Coordinated the development and maintenance of an intranet site for improved provider communication .
- Analyzed data and statistics regarding the CMS PQRI (Physician Quality Reporting Initiative), payer data, and other sources.
- Assisted with the design and implementation of a telemedicine research project for the Diabetes population.
- Analyzed technical process related to the implementation of a Diabetes registry with interface capabilities for a proposed EMR system.
- Created Provider Scorecards to monitor PQRI performance and benchmarking.
- Served as health informatics intern under Boise State University.
- Ambulatory Care Focus - Participate in medical record conversion project to prepare for EMR implementation.
- Long Term Care and Skilled Nursing Focus - Coordinate MDS (Minimum Data Set) data collection and submission to include timeliness and accuracy.
Ms. King received her BS in Health Informatics and Information Management from Boise State University. She is a Registered Health Information Technician with the American Health Information Management Association, and a member of the Health Care Compliance Association.