Open to opportunities

Nyema Jones

@nyemajones

Detail-oriented healthcare operations professional specializing in provider enrollment, quality assurance, and claims accuracy.

United States

Message

What I'm looking for

I’m looking for a compliance-driven healthcare role where I can lead HIPAA-compliant quality audits, verify provider/claims data, resolve discrepancies, and drive process improvement—partnering with a team that values accuracy and confidentiality.

I’m a detail-oriented Healthcare Operations, Provider Enrollment, Quality Assurance, and Claims Processing professional with 9+ years of experience supporting healthcare administration, provider data management, compliance auditing, documentation review, claims resolution, and quality assurance initiatives. I bring strong experience with Medicaid programs and HIPAA compliance, focused on safeguarding confidential information while maintaining accuracy in high-volume environments.

In my Quality Assurance Coordinator role, I review participant files and documentation for compliance, accuracy, and completeness. I perform quality audits, validation checks, reporting, reconciliation, and data analysis, then identify discrepancies and implement process improvement recommendations. I also maintain accurate electronic records with strict attention to confidentiality.

Previously, I served as an Electronic Visit Verification Specialist / Claims Coordinator, where I reviewed documentation for Medicaid compliance and accuracy and investigated claim discrepancies to resolve billing issues. I handled data verification and quality control reviews while maintaining HIPAA compliance and coordinating with providers and managed care organizations.

Across roles including Service Coordinator / Plans Department, Quality Assurance Specialist, and Claims Examiner, I’ve consistently ensured documentation accuracy and regulatory compliance, acted as a liaison among participants, providers, and government agencies, and strengthened data integrity through audits and database entry. I’m energized by work that combines compliance, quality, and continuous improvement supported by tools like Microsoft Excel and reporting & analysis.

Experience

Work history, roles, and key accomplishments

Current

Electronic Visit Verification Specialist

Current

Connecting Bridges Home Care Agency

Sep 2021 - Present (4 years 9 months)

Reviewed healthcare documentation for Medicaid compliance and accuracy and investigated claim discrepancies to resolve billing issues. Performed data verification and quality control reviews while maintaining HIPAA compliance and coordinating with providers and managed care organizations.

Medicaid Compliance Data Verification Quality Control HIPAA compliance Documentation Discrepancies Provider coordination

Current

Quality Assurance Coordinator

Current

JEVS Human Services

Jul 2020 - Present (5 years 11 months)

Reviewed participant files and documentation for compliance, accuracy, and completeness, performing quality audits and validation checks. Identified discrepancies, supported reporting and reconciliation, and recommended process improvements while maintaining confidential electronic records.

Quality Assurance Compliance Auditing Data Validation Reporting Analysis Documentation Review Medicaid Programs HIPAA compliance Reconciliations Process Improvement

Service Coordinator (Plans)

Care 365, Inc.

Sep 2018 - Sep 2019 (1 year)

Managed participant records and service plans in HCSIS and SAMS, ensuring documentation accuracy and regulatory compliance. Served as a liaison among participants, providers, and government agencies to support plan delivery.

Service Coordination SAM Regulatory Compliance Provider Liaison Healthcare Administration

Service Representative / Effects Clerk

Medical Examiner's Office of Philadelphia

Jun 2016 - Mar 2018 (1 year 9 months)

Maintained confidential records and processed affidavits, death certificates, and statutory records with careful electronic documentation management. Provided administrative support and records management to ensure timely handling of sensitive documentation.

Records Management Affidavit Processing Administrative Support Data Entry Compliance Driven Handling Quality Assurance

Quality Assurance Specialist

Philadelphia Youth Network

Apr 2016 - Jun 2016 (2 months)

Reviewed participant files for eligibility, accuracy, and compliance, performing quality reviews and database entry. Supported consistent documentation standards through detailed file verification.

Quality Assurance Compliance Documentation Review Verification Process Adherence Healthcare Operations

Third Party Liability Specialist

Southwest Nu-Stop

Aug 2012 - Nov 2012 (3 months)

Verified insurance eligibility and processed claims information while resolving discrepancies with insurance carriers. Maintained accurate records to support clean claim processing.

Third Party Liability Claims Processing Records Management Healthcare Billing Support Quality Control

Quality Assurance Assistant

Southwest Nu-Stop

Aug 2011 - Nov 2012 (1 year 3 months)

Audited 500+ medical charts for compliance and documentation integrity, performing document control, quality reviews, and data entry. Ensured accurate documentation and maintained quality standards across high-volume records.

Document Control Quality Data Entry Compliance Auditing Data Quality Healthcare Documentation