Health Insurance A/R Collections Denial Root Cause Analyst (Portland/Gresham)

James Joyner
Portland, OR 97233

Medical Claims Background, Knowledge, & Experience:

Reimbursement/Collections/Aging/Denial/Appeals Specialist, Claims Adjuster & Auditor, Revenue Cycle Analyst, C.O.B/Subrogation Rep, Revenue Recovery Coordinator, Payer & Provider Contracts Associate, Credentialing Rep, Compliance Representative and more.

Work Experience:

Portland, OR
Medical Reimbursement/Denials Specialist/Claims Auditor
01/09 – Current

Auditing of Medical Receivables (Denied/Suspended/Underpaid Claims) for reversal opportunities.
Review explanation of benefits to determine payment denials and resubmit corrected claims.
Collaborate with Practice/Billing Manager to discuss admin procedures that affect reimbursement.
Post insurance payment (Allowable) info for corrected billing/coding, then submit to secondary payer.
Appeal or request claim reprocessing to represent Correct Adjudication of Compliant Billings.
Read, interpret and comprehend insurance payment Remittance Advice
Share Advance knowledge of medical insurance operating procedures, practices, and shortcomings.

Pace Staffing Network
Seattle, WA
Group Health ( Now Kaiser) Processor 2 (Adjuster)
10/07 – 05/08

Reprocess claims from medical healthcare providers that requested an adjustment or payment review.
Monitor medical claims for billing or coding errors and uncovered items or services.
Audit claims daily using statistically valid sampling methods, in order to perform complex adjustments.
Determine accurate payment criteria for clearing pending claims based on defined Policy and Procedure.
Consistently meet company productivity goals, quality standards and aging time frames.

Pace Staffing Network
Mill Creek, WA
Apria - DME Claims Biller/AR Specialist
06/06 – 10/07

Reduced DME Aging/Receivables (and Backlog) ahead of predicted analysis for all payers
Investigate delinquent accounts; contact third party reps to facilitate payments and note patient record.
Identified & communicated payer partial payment and denial patterns impacting revenue to billing manager.
Analyzed payer reimbursement & denial trends in order to minimize denials and maximize reimbursements.
Verify diagnosis and service coding to ensure integrity in order to reduce rejections or partial payments.

Bryman (Everest) College
Renton, WA
Medical Insurance Billing and Coding Instructor
02/05 – 05/05

Prepare students for careers in Medical Insurance Billing, Coding, Claims Processing and Adjudication for both Healthcare provider organizations & Insurance Company’s.
Sit-down with each student bi-weekly to provide feedback designed to keep them focused and motivated.

Insurance Overload Staffing
Renton, WA
Practice Management Software Implementation/Biller/Coder
01/03 – 02/05

Project Lead for implementing and transitioning the Hearing, Speech, and Deafness Center’s 100,000 Patient and Vendor base from outsourced billing to in-house Meditech Medical Management System.
Installed and configured the fully customizable Meditech Medical Management System.
Created charge description master, set-up & testing with claims clearinghouse, physician scheduling, patient and payer file information. Initiated document imaging to PDF files for faster retrieval and loss prevention.
Trained staff on software functionality and coordinated front to back office admin procedures. Data entry of all insurance information for each patient. Order CMS-1500 claim forms.

Healthcare Resource Staffing
Sand Point, ID
Providence Medical Center HIM ASC Coder
06/02 – 12/02

Abstracted Diagnosis, Service, and Supply related information from Outpatient and ASC patient Medical Record and use ICD-9, CPT-4, and HCPC Coding manuals to assign the appropriate codes to a CMS-1500 or UB04 form.
Used Transcribed Physician Notes, Lab Tests Results, Imaging studies, and other sources to report services and verify work/medical services performed on the patient’s behalf.
Audit and Re-file appeals of denied claims, educate physician & patient about coverage or Medical Necessity.

Insurance Overload Staffing
Renton, WA
Medical and Dental Claims Adjuster
01/02 – 06/02

Verified, calculated, and applied pricing amounts to facility claims. Analyzed patient record to determine medical necessity for the provided treatment, diagnostic testing, or hospital admission.
Reviewed insurance remittance to verify reimbursement is correct and make adjustment to patient account.

Guidance Staffing Inc.
Federal Way, WA
Medicare Biller/High Dollar Claim Representative
09/01 – 01/02

Recouped $23.7 Million in denied High Dollar Medicare Oncology (Epoetin) claims (>800) in 68 Business days for Multicare healthcare.
Call patients on outstanding balance, and if necessary, setup payment plan in hopes of securing payment.
Gather supporting documentation and quickly file appeal with carrier based on factual benefit information.
Significantly decreased standard claim payment turnaround time by efficiently managing claims and taking advantage of the CMS online claims adjustment and re-submittal system/portal.

Education, Training – Software Experience

American Medical Billing Association
Medical Reimbursement Specialist Certification
American Medical Billing Association
ICD-9, CPT-4, HCPCS I-II Competency Testing
U.S. Army, Ft. Sam Houston, TX
Army Combat/Field
Medical Specialist Course

Windows Operating Systems
Office Ally – Practice Fusion
Microsoft Office
Medical Claims Adjudication Class
Meditech Practice Mgmt Software
kareo EHR
  • Principals only. Recruiters, please don't contact this poster.

post id: 7752502120



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