Jonalyn De Tomas, CPC
Summary
Versatile healthcare professional with experience in medical coding, utilization management, home health billing, and claims follow-up. Strengths include cross-functional collaboration, data verification, and workflow support across providers, office staff, and payers. Committed to timely reporting, compliant documentation, and reliable results.
Overview
22
22
years of professional experience
Work History
Medical Coding Analyst
PIH Health - Risk Adjustment Dept.
06.2024 - Current
- Safeguards and preserves the confidentiality of patient’s protected health information in accordance with State and Federal (HIPAA) regulatory requirements, hospital and departmental policies.
- Ensures a safe patient environment and adherence to safety practices per policy.
- With consideration to age, employee utilizes the approved process to resolve biophysical, psychological, educational and environmental needs of patient/significant other when administering care.
- Conducted comprehensive chart reviews and data mining for physician offices. for PCP and SCP physician offices with Senior Coding Analyst.
- Identified and documented missed billing opportunities for diagnoses in physician offices. of diagnosis not billed by physician office.
- Participate in the PHASE/PAHAF Quality Incentive Program with the Group physicians.
- Provide concurrent feedback to Group Physicians on charting and coding in regard to Quality Initiatives.
- Assist with follow up for encounter data submission errors.
- Supported staff in identifying and measuring clinical data for quality incentive programs. in the identification, completion, and measuring of clinical data for the quality incentive programs.
- Provide staff support in focused studies for clinical indicators as pertained to Quality Incentive Program and Star Measures.
- Collaborated effectively with providers and office managers to ensure timely health plan reporting. with providers and office managers to ensure timeliness of health plan reports and Sweeps for medical record information pertaining to Risk Adjustment.
- Performs all other duties as assigned.
Home Health Representative
PIH Health Home Health Dept.
07.2023 - 06.2024
- Managed timely and accurate billing of commercial/group insurance, Medicare, managed care, and self-pay home health accounts.
- Recorded payments and remittance advices accurately in the billing system.
- Conducted thorough reviews of unpaid claims and patient accounts to identify issues.
- Use procedural guidelines to reduce the outstanding dollars on accounts receivable.
- Billing and electronic submission of claims; performing consistent collection and accounts receivables follow-up practices; processing and posting of payments
- Identified and prepared necessary write-offs for uncollectible accounts to maintain accuracy.
- Resolved all credit balances accurately and in a timely manner to ensure compliance.
- Response to assigned payer correspondence to ensure proper claim reimbursement.
- Identifying gaps in submissions, ensuring correct data are being
- submitted by the clinical staff before sending in a timely manner to Medicare and other payers . Verifying areas that need improvement and missing information for adjustments before submissions.
- Verified patient eligibility and communicated with the Managed Care Liaison to correct payer information.
- Verifies all pertinent data for completeness and accuracy.
- Sent correspondence to clinical staff requesting missing documentation and necessary information.
- Distributed monthly statements of balances due and charity applications to patients.
- Compiled reports on aging activities and conducted follow-ups on outstanding accounts.
Utilization Management Coordinator
Network Medical Management, Inc.
03.2020 - 07.2023
- Process and edit Routine, Retro & Urgent treatment authorization requests
- Obtained authorization approvals from the appropriate physician.
- Answer all incoming calls and e-mails with respect to general information regarding an authorization
- Sent all approval and modification letters out.
- Modification letters are faxed occasionally, per the request of providers/specialists
- Verify patients Benefits and Eligibility for all authorization of services
- Calling and submitting electronically health plan for pre-certification of
- Medications, DME, home health, outpatient and inpatient services
- Checking Global Day periods procedure code requirement, CCS Eligibility,Preclusion Provider List from OIG and SAM
- Review clinical notes from medical providers
- Check and modify appropriate ICD-10, HCPCS and CPT Codes
- Verifying DOFR (Division of Financial Responsibility
COBRA/ Billing and Collection Coordinator
Printing Industries Assoc. of Southern California
04.2005 - 08.2019
- Reviewing patient medical bills,correspondence and EOB's for accuracy
- Communicating with Insurance Companies and Providers to address any issues that are identified (e.g., appeal incorrectly denied claims, coordinate with providers to fix billing errors, negotiate with providers in the case of inappropriate billing)
- Communicating with clients via phone and email - responding to client requests
- in a timely and professional manner, going above and beyond to make sure their
- concerns are addressed and that medical bills and associated paperwork are no
- No longer a worry for them
- Provide client support with benefit/health insurance questions
- Identifies problems and inconsistencies by using management reports
- Summarizes findings and makes recommendations to resolve claims/billing issues
- Create spreadsheets for billing & collection reports.
- Received and screened a high volume external and internal communications,including email and mail Process COBRA Election forms
- Enroll, Reinstate and terminate coverages with the carriers
- Created excel spreadsheets to track insured's data and perform an intense reconciliation process
- Typed memos, correspondence, reports and other documentation including follow-up letters to customers to ensure their questions were answered in a timely manner
- Follow-up phone calls and sending out monthly notices for medical premium and pending premiums
- Electronically submitting claims, appeals and discrepancy billing issues to health plan.
Education
American Academy of Professional Coders
Skills
- ICD-10 coding
- Risk adjustment
- Chart review
- Claims editing
- Medical billing
- Prior authorization
- Benefits verification
- Denial management
- Accounts receivable
- Attention to detail
- Cross-functional collaboration
- Critical thinking
- Workflow optimization
- Procedural coding accuracy
- Clinical documentation review
- CPT coding
- HIPAA compliance
- Electronic health records experience
- Continuous learning mindset
- ICD-10 proficiency
- Document management
- Data verification
Timeline
Medical Coding Analyst
PIH Health - Risk Adjustment Dept.
06.2024 - Current
Home Health Representative
PIH Health Home Health Dept.
07.2023 - 06.2024
Utilization Management Coordinator
Network Medical Management, Inc.
03.2020 - 07.2023
COBRA/ Billing and Collection Coordinator
Printing Industries Assoc. of Southern California
04.2005 - 08.2019
American Academy of Professional Coders