MARK JONES-STOCKLI

Support fraud, waste, and abuse detection in a prepayment environment, reviewing claims for improper billing and collaborating with investigators and clinical teams to ensure compliance. Contribute to cost avoidance efforts and support business initiatives through data analysis and reporting.

Directed daily operations for return check and recovery workflows, handling 50-100+ claims per week and conducting fraud and overpayment investigations. Managed workload distribution across a team, developed operational reports, and trained and mentored team members.

Audited 100+ Medicare appeals monthly, ensuring compliance with CMS, NCQA, and URAC standards, and maintained a 98-100% audit accuracy level. Served as primary liaison for external auditors and supported accreditation readiness.

Managed 200-400+ cases per month while meeting strict regulatory turnaround requirements, collaborating with medical directors, legal teams, and operations partners. Recognized as SME for appeals workflows and regulatory compliance.

Processed 100+ claims daily to support revenue cycle operations and accurate reimbursement, reducing denial resolution time through detailed claim review and correction. Managed payments, collections, and refunds with high financial accuracy.

Maintained a 99% accuracy rate across high-volume claims adjustments and supported recovery efforts, including high-value claim corrections up to $1M. Audited work, recommended process improvements, and trained and mentored claims analysts.

Bachelor of Arts in Psychology with a minor in Biology from Lyon College.