KIMALEE JONES

Investigate complex documentation, regulatory requirements, and supporting evidence to identify discrepancies, compliance concerns, and risk indicators requiring escalation.

• Conduct approximately 4 compliance reviews weekly, including in-depth audits involving documentation quality, policy interpretation, and regulatory compliance.
• Analyze documentation to determine completeness, accuracy, and adherence to internal policies, payer requirements, and applicable regulations.
• Prepare concise, defensible findings and recommendations supporting leadership decision-making and operational improvements.
• Collaborate with cross-functional stakeholders to resolve documentation issues, improve workflow quality, and strengthen compliance initiatives.
• Manage multiple concurrent priorities while consistently meeting quality standards and critical deadlines.
• Recognized by leadership for analytical decision-making, documentation accuracy, and willingness to assume additional responsibilities.

• Performed risk-based audits to evaluate documentation integrity, billing accuracy, supporting evidence, and regulatory compliance.
• Identified recurring documentation trends, operational risks, and process deficiencies impacting claim outcomes and organizational compliance.
• Investigated documentation discrepancies and partnered with operational teams to implement corrective actions and improve workflow effectiveness.
• Maintained detailed audit trails and defensible documentation supporting internal and external reviews.
• Assisted in developing and improving compliance processes that strengthened documentation quality and reduced operational risk.
• Built a reputation for thorough investigations, objective analysis, and high-quality documentation.

• Directed internal audits across claims, appeals, and operational processes to evaluate documentation quality, compliance, and adherence to organizational standards.
• Investigated complex claim files to identify documentation deficiencies, regulatory concerns, policy interpretation issues, and potential operational risk.
• Prepared clear findings and actionable recommendations for leadership to support informed business decisions.
• Mentored and trained audit staff on investigative techniques, documentation standards, quality expectations, and defensible file handling.
• Collaborated with leadership to strengthen internal controls, improve documentation quality, and enhance regulatory compliance.
• Recognized for leadership, analytical expertise, and continuous process improvement.

• Adjudicated up to 300 healthcare claims weekly while maintaining strict documentation accuracy, quality standards, and regulatory compliance.
• Reviewed and resolved 75–100 appeals weekly, evaluating supporting documentation, policy guidelines, and claim information to determine appropriate outcomes.
• Investigated documentation discrepancies, billing issues, policy interpretation questions, and potential compliance concerns to support timely claim resolution.
• Maintained accurate, defensible claim documentation and tracked follow-up activities throughout the claims lifecycle.
• Identified recurring trends, documentation deficiencies, and process improvement opportunities through ongoing claim analysis.
• Trained and mentored team members on claims accuracy, documentation requirements, quality expectations, and regulatory compliance.
• Earned recognition for consistent performance, analytical decision-making, and reliability in high-volume production environments.