Office Manager Document Management
Resume:
Donna D. Jones
Houston, TX 77014
**********@*****.***
Experienced Office Manager with 27+ years of experience specializing in Healthcare, Medical Billing, Front-End Billing, Insurance Billing, Payment Posting, Document Management, Central Scheduling, PTO Requests, Payroll, Recruiting, and Accounting, within an office setting.
SKILLS
ICD-9 & ICD-10
CPT-4
HCPC procedural coding
ADA Dental codes
CDT-7
CRPC
EOB interpretation
Medical Terminology
Microsoft Office
Excel & Power Point
PDMS/Core
SMS Care & IDX System
Commercial & Governmental Billing
Home Infusion Billing
HIPAA
CMS guidelines for Medicare and Medicaid billing compliance
Thin/Availity Billing Software
Cirius/Prebill Billing System
Citrix
Front-End Billing & Back-End Processes
Document Management
Kronos
ImagineNow6
Allscript. ETM
Remit Data
Claims Logic
Easy Print
Ecomm
EPIC-Super User
DHS
Change Healthcare (Emdeon)
Ability (FSS)
Compliance 360
Facets
Xcelys
PROFESSIONAL EXPERIENCE
Kelsey Seybold Clinic; Pearland, TX Nov 2022 – June 2025
KCA Medicare Claims Analyst, Remote
Responsible for the adjudication of complex facility claims including hospital, durable medical equipment, home health services, home infusion, skilled nursing facilities as well as associated professional claims.
Essential job functions include Apply knowledge of Centers for Medicare & Medicaid Services (CMS) rules specific to DRG pricing methods, APC, Outpatient Prospective payment system mechanics (OPPS) and Contractual Payment Rates.
Work closely with Supervisor and Claim Services to complete request for claims adjustments via CRM Module.
Review and interpret provider issues, document management and member reimbursement requests. Utilize DRG and other pricing tools and apply applicable reimbursement outcomes claims.
Conduct pre/post analysis of high dollar claims and present summary to management.
Kelsey Seybold Clinic; Pearland, TX June 2021 – Nov 2022
Insurance Follow Up Rep II, Remote
Responsible for physician & hospital billing, home infusion billing and collecting of third-party account receivables using their knowledge of medical software, the EHR, and multiple payors’ insurance websites to research accounts, refile or appeal claims, submit additional medical documentation, track account status by monitoring and analyzing assigned unresolved third-party accounts and reimbursements.
Responsible for inventory of over $1M in insurance receivables.
Initiated contacts and negotiated appropriate resolution (internal and external) as well as receiving and resolving inquiries and correspondence from third parties and patients.
Analyzing, auditing, problem solving, document management and reconciling an account is critical to this position. Conducts duties in accordance with industry federal and state billing guidelines and contractual obligations and in compliance with department policies and procedures.
Meet deadlines, and appropriately analyze, research, and resolve problems in a fast-paced environment with constant work-related interruptions.
Communicating with external contacts and patients to explain patient financial liability, advise of non-coverage, process payments and payment plans, clarify Explanation of Benefits and statement of physician services.
Houston Methodist Hospital; Houston, TX April 2018 – June 2021
Medicare Billing & Follow Specialist, Hybrid
The Medicare Specialist (MS) is responsible for the billing and follow-up of Medicare accounts receivable.
Front-End Billing of all specialties, home infusion, oncology, DME, cardiology etc.
The MS is considered an expert in Medicare billing guidelines. This includes preparing and processing claims; clearing billing edits; claim validation and submittal; and receivable follow up to ensure that claims are paid timely, accurately, and compliantly.
Ensure that all claims billed are compliant with state and federal regulations related to the Medicare program, and all payments received by the Medicare program are correct.
Have a solid working knowledge of patient account receivable. In addition to billing Medicare guidelines, this includes knowledge of Patient Access Services/Admissions, Case Management, Medical Records Coding, Collections, Charge Review, Medicare payer systems (FSS), Document Management and post payment activities.
Possess expert knowledge of the Medicare program; can partner with various hospital departmental counterparts, and the ability to communicate verbally and in writing.
Follows general policy and procedures (i.e., Attendance, Dress Code, Call in Procedures, Levels of Authority, etc.) and able to accept feedback from Management in a positive manner and implement improvements where indicated.
Follows levels of authority for posting adjustments, refunds, and contractual allowances. Posts adjustments accurately as stated on Medicare RA or 835. (EF)
Have working knowledge of the Medicare Electronic Data Interchange (EDI) process including 837 creation and submittal, Medicare Shared System processing and status locations, transmittal balancing, and 835 processing.
Manages time effectively to report to work as scheduled; to meet quality and productivity standards; and to meet project due dates.
Responds to other departments when Medicare claim processing information is needed. This can include working with management to respond to internal audit, case management, Medical Records, etc. (EF).
Responds appropriately, thoroughly, and timely to patient related issues and/or questions. This can be requests from customer service call center, patient correspondence, or patient requests originating from other hospital departments or management. (EF)
Houston Methodist Hospital; Houston, TX April 2018 – June 2021
Medical Payment Poster Specialist, Hybrid (during overtime)
In-Depth processing of manual and ERA payments and adjustments received
Works in multiple systems ensuring all insurance payments are accurately posted and reconciled
Responsible for balancing batches assigned daily and reporting any batch issues to their immediate manager/or supervisor for prompt resolution
Perform extensive primary and secondary research to locate missing EOB's and insurance payments for posting to accounts
Retrieve missing payment information from payers through various methods (phone, payer portals, clearing houses, etc.)
Interpret, evaluate and clarify research requests to determine potential payment issues
Identify underpayments and overpayments/credits and notify the Supervisor/Manager in a timely manner for resolution
Research and resolve deposit and/or posting discrepancies
Assist in the controls, balances and deposits of daily cash receipts to maximize return.
Responsible for compliance with applicable laws, rules and regulations impacting cash management services.
Collaborate with teammates to ensure the departmental close for each month is met within the first 3 business days of the following month.
Must be able to read debits and credits on accounts and take necessary action to resolve
Assists with related special projects as required.
Perform other duties assigned by the supervisor
ECM Insurance Agency, LLC; Houston, TX Nov 2017- April 2018
Licensed Insurance Agent
Develop positive working relationships with clients.
Approach clients via cold calling and direct mail to inquire about their insurance situations and future needs
Deliver policy proceeds after a claim is filed and approved
Communicate with Insurance Adjusters about the life cycle of each claim
Explain the differences in policy specifics so clients can make informed decisions about their purchases
Assist with obtaining underwriting approval
Respond to clients' questions and complaints
Follow up with clients after initial meetings or conversations
Participate in continuing education programs in both insurance and sales
Acclara Solutions LLC; Houston, TX Feb 2017- July 2017
Supervisor, High Dollar
Manage and coordinate the daily operations of the High Dollar Customer Service Department and follow up/claims collection activities for 19 employees.
Monitor employees’ QA work performance/productivity and make recommendations where and when needed.
Demonstrated knowledge and experience in Human Resources best practices with emphasis on employee relations as well as related federal, state, and local laws and regulations.
Strong time management, detail-orientation, and organizational skills with the ability to effectively multi-task and prioritize.
Mentor, coach and train new hire and team members
Statistical reporting; generates/complies production, accounts receivable, employee personal reports
Strong customer service experience in a team environment.
Participates in hiring of qualified, competent personnel.
Builds, maintains, and promotes relationships with team members, peers across disciplines, sales staff, and all other company team members ensuring effective coordination of communications and services affecting clients.
Completes regular reviews of staff timely
Determine areas of improvement and efficiency gains with assigned staff and processes
Works with management in overseeing special projects.
Support senior leadership decisions and processes providing constructive feedback
Review and interpret patient statements for balance accuracy and client contractual terms/agreements
Interacts with client and/or insurance companies on a daily, or as needed, basis to ensure that the information being exchanged maximizes reimbursement, to include incoming client calls regarding status of accounts or client and patient complaint calls.
Investigates client concerns and communicates operational issues and improvement processes to project teams and management.
Ensures accounts are being resolved in a timely manner and provides support and training on call management and collection techniques.
Active call listening, call barge as necessary and quality monitoring of personnel
MD Anderson Cancer Center; Houston, TX Feb 2014 – Feb 2017
PBS Billing Specialist – Research Billing
Analyzed and resolved clinical research patient accounts and resolved all account discrepancies including credit balances
Reviewed accounts and identified charges billable either to insurance or to the clinical research study
Ensured all necessary information is received to substantiate charges
Processed On/Off-Study Notifications
Performed research ticket processing, charge validations and memo billing of research charges
Identified and resolved issues with the billing process
Maintained clinical billing procedures and identifies process improvement initiatives
Responsible for ensuring all charges related to clinical research activities are billed appropriately
Billed physician & hospital claims & follow-up/claims collection according to governmental and commercial billing regulations
Performed Medicaid, Medicare, and Commercial collection activities including appeals
Completed daily response and rejection reports for denials
Analyzed and resolved all account discrepancies including credit balances
Performed insurance verification functions to expedite insurance billing & payments
Utilized carrier websites to research change request updates for Medicaid and Medicare, review LMRP diagnosis and CCI edits
Ensured that governmental and coding regulations are followed according to Medicaid and Centers for Medicare and Medicaid
Billed physician & hospital claims & follow-up/claims collection according to governmental billing regulations
Performed Medicaid collection activities including appeals
Completed daily response and rejection reports for denials
Analyzed and resolved all account discrepancies including credit balances
Performed insurance verification functions to expedite insurance billing & payments
Utilized CMS & TMHP website to research change request updates for Medicaid, review LMRP diagnosis and CCI edits
Ensured that governmental and coding regulations are followed according to Medicaid and Centers for Medicare and Medicaid
Kept abreast on Newsletter updates for billing and claims collection procedures under Medicaid guidelines
MD Anderson Cancer Center; Houston, TX Nov 2011 – Feb 2014
Payment Posting
Provided analytical support and specialized billing processes for Patient Business Services (PBS).
Scoped Impacts Patient Business Services and the patient population.
Performed account analysis, maintenance, and follow-up activities and appeals on insurance, self-pay, bad debt, and charity care accounts, as appropriate.
Posted payments and resolve credit accounts.
Reconciled and analyzed various payments for accuracy.
Tracked account statuses and reports issues to management.
Generated and reconciles system generated reports, providing statistical data/trends to management.
Processed primary and secondary claims and late charges.
Provided customer service support by resolving account inquiries, reconciling vendor invoices, and generating itemized statements.
McKesson; Houston, TX Jun 2010-Nov 2011
Manager- Revenue Cycle I
Responsible for quality assurance for all aspects of team’s claims collection performance through call monitoring, and monthly account reviews, and federal and company compliance training
Recruited for all department open positions, Interviewed, Hired, and Trained New employees
Demonstrated knowledge and experience in Human Resources best practices with emphasis on employee relations as well as related federal, state, and local laws and regulations.
Strong customer service experience in a team environment.
Interacted with client and/or insurance companies on a daily, or as needed, basis to ensure that the information being exchanged maximizes reimbursement, to include incoming client calls regarding status of accounts or client and patient complaint calls
Investigated client concerns and communicates operational issues and improvement processes to project teams and management
Strong time management, detail-orientation, and organizational skills with the ability to effectively multi-task and prioritize.
Ensured accounts are being resolved in a timely manner and provide support and training on call management and collection techniques
Tracked trends of client specific issues with carriers and internal processes
Completed Recon monthly to include resolving issues with data integrity or client processes
Completed monthly QA reviews on staff to evaluate quality of work and adherence to time and attendance guidelines and other company policies and procedures
Communicated with management on project/team performance issues
Communicates tactfully and effectively, verbally and in writing, with all levels of organization and maintains effective work relations with those encountered in the course of employment. Able to communicate to a wide audience and translate complex human resources issues and concepts into understandable terms.
Managed the daily project data and workflow of Reimbursement Specialists to ensure monthly revenue goals are consistently met
Motivated and mentored staff to achieve monthly revenue goals and overall associate development
Builds, maintains, and promotes relationships with team members, peers across disciplines, sales staff, and all other company team members ensuring effective coordination of communications and services affecting clients.
Oversee staff meetings and communicate issues to management
Completed time and attendance system corrections to include delivering disciplinary actions for first and second level occurrences
Monitored the quality of work produced by reimbursement specialist to ensure adherence to customer service/self-pay project requirements and provides constant feedback
Administered company policies and procedures in conjunction with documentation of action plans to improve performance
Reviewed internal reports and communicate with clients to ensure information passing between client and the EBO is accurate
Identified areas and implement methods to address individual and team training needs
Resolved issues with the processing of demographic, transaction and reconciliation files in claim follow up system
MD Anderson Cancer Center; Houston, TX Jul 2001 – Jun 2010
Supervisor- PBS Billing
Managed and coordinate the daily operations of the AR/Billing unit and billing of Governmental, Commercial, Managed Care, and follow up/claims collection activities for 24 employees
Recruited for all department open positions, Interviewed, Hired, and Trained New employees
Strong customer service experience in a team environment.
Monitored employees’ QA work performance/productivity and make recommendations where and when needed
Strong time management, detail-orientation, and organizational skills with the ability to effectively multi-task and prioritize.
Demonstrated knowledge and experience in Human Resources best practices with emphasis on employee relations as well as related federal, state, and local laws and regulations.
Performed yearly employee evaluations and responsible for setting employee/ departmental goals
Builds, maintains, and promotes relationships with team members, peers across disciplines, sales staff, and all other company team members ensuring effective coordination of communications and services affecting clients.
Responsible for establishing departmental policies and procedures
Participated in appropriate committees relating to AR/billing changes and requirements to existing and new programs and/or policies
Analyzed, prepared, and maintained weekly financial reports for management regarding statistical data on billing and claim collection activities
Prepared and created pie charts, bar graphs, line graphs, and excel spreadsheets for the reporting of our daily/ weekly/monthly revenue collections, patient enrollment, provider capitation payments, generations of monthly invoices, and total charges billed
Developed and present Power Point presentations for operations and training purposes
Monitored and analyzed transmission and acceptance reports to identify any claims processing rejection issues for purposes of ensuring consistent cash flow
Monitored CMS, Trailblazer, TMHP, UHC, etc, websites for new changes for facility and professional requirements as related to billing, charge capture, registration, enrollment / disenrollment regulations and compliance
Uploaded quarterly CCI & LCD edits into the Prebill Cirius billing system and assist with creating modified edits to increase percentages of clean claims
Confers with payers and Thin Clearing House regarding batch & claim rejections and delinquent accounts to determine appropriate action needed to reconcile
Interviewed and trained new hires, and responsible for performance evaluation process and make recommendations for personnel actions
Completed weekly Kronos/employees timecards and reporting
Project management skills and experience managing multiple projects.
Correspond on a regular basis with IT in communicating the billing department needs about reporting and system changes
Billed physician & hospital claims & follow-up/claims collection according to governmental billing regulations
Performed Medicare & Medicaid claim collection activities, including appeals
Corrected billing rejections online via Medicare GP Net
Completed daily response and rejection reports for denials
Analyzed and resolved all account discrepancies including credit balances
Performed insurance verification functions to expedite insurance billing & payments
Utilized CMS, TMHP & Trailblazer website to research change request updates for Medicare, review LMRP diagnosis and CCI edits
Ensured that governmental and coding regulations are followed according to Medicare Part B and Centers for Medicare and Medicaid
Kept abreast on Newsletter updates for billing procedures under Medicare Part B guidelines
MD Anderson Cancer Center; Houston, TX Jul 2000 – Nov 2010
PBS Associate – Customer Service/Payment Posting
Provided analytical support and specialized billing processes for Patient Business Services (PBS).
Scoped Impacts Patient Business Services and the patient population.
Performed account analysis, maintenance, and follow-up activities and appeals on insurance, self-pay, bad debt, and charity care accounts, as appropriate.
Posted payments and resolve credit accounts.
Reconciled and analyzed various payments for accuracy.
Tracked account statuses and reports issues to management.
Generated and reconciles system generated reports, providing statistical data/trends to management.
Processed primary and secondary claims and late charges.
Provided customer service support by resolving account inquiries, reconciling vendor invoices, and generating itemized statements.
First Health Ins; Houston, TX May 2000 – Jun 2001
Sr. Benefit Examiner
Processed commercial and governmental physician, hospital, and dental claims according to their contract agreements and regulations
Audited claims, processed appeals, adjustments, reimbursements, and reconciled correspondence
Reviewed patient’s accounts to identify credit balances, post debits and credits
Reviewed weekly reports to identify delinquent and unpaid claims
Memorial Sister of Charity/Humana; Houston, TX Sep 1999 – May 2000
Claims Processor
Responsible for processing Governmental Physician and Hospital claims by governmental regulations & guidelines
Audit claims, processed appeals, adjustments, reimbursements, and reconciled correspondence.
Review reports for credit balances, post credits and debits
Baylor College of Medicine; Houston, TX Dec 1998 – Sep 1999
Sr. Professional Fee Clerk
Responsible for physician & hospital billing for governmental, commercial, and managed care payers
Posted and prepared cash deposits and charged entry
Resolved billing inquiries by phone and one-on-one meetings with the doctors
Printed acceptance and rejection reports, and resolve batch rejections
Reviewed weekly reports to identify unbilled charges, credit balances, and unbilled account
Processed charge corrections, refunds, and reconciled correspondences
Memorial Sister of Charity/Humana; Houston, TX Mar 1998 – Dec 1998
Claims Processor
Audit claims, processed appeals, adjustments, reimbursements, and reconciled correspondence.
Review weekly reports to identify delinquent and unpaid claims
Review reports for credit balances, post credits and debits
Spectera Dental Insurance (Pacific Care Dental); Houston, TX Aug 1996 – Feb 1998
Claims Processor
Processed Dental and Vision claims according to their contract agreements.
Audit claims, processed appeals, adjustments, reimbursements, and reconciled correspondence
EDUCATION
Houston Community College, Houston, TX 1991 Some college courses completed
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