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Medical Claim Denial/Reversal/Reimbursement Revenue Cycle Management (Portland/Gresham)

available afternoons
available mornings
available weekdays
education completed: high school/GED

James Joyner

Portland, OR



Medical Claims Background:

Extensive HMO, PPO, Medicare, Medicaid, and Commercial medical claims experience as a Biller, Coder & Coding Instructor, High-Dollar Reimbursement/Collections Rep, Denials & Appeals coordinator, Processor, Adjuster, & Auditor, Benefits Specialist, and Provider Network Builder in addition to a referral, provider, and member benefits representative for Physicians, Hospitals, Payers, and Third Party Administrators.

Work Experience:

Portland, OR
Medical Insurance Claims & Reimbursement Consultant
01/09 - Current

Analyzed medical provider's receivables and administrative procedures to identify underlying problems.

Demonstrated collection techniques that get multiple claims paid & keep the Primary insurance A/R below days.

Educated providers on the importance of properly documenting the patient record in order to reduce medical necessity denials or payment reversals submitted by insurance claims auditors.

Worked with provider billing rep to prevent the most common physician billing & coding mistakes.


Pace Staffing Network
Seattle, WA
Group Health - Claims Processor II (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 non-covered items or services.
Negotiated payment amounts for new or out of network fee-for-service medical providers submitting claims under $10K.

Monitor claims for possible incorrect billing and conferring with patients and doctors to gather additional information for correct adjudication.


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

Reduced insurance receivables in excess of 150-days to under 30-days (average) in less than 5-weeks, which increased overall monthly revenue.

Investigated 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.

Run daily, detailed aged receivables, physician & patient financial reports for month end closing.


Bryman (Everest) College
Renton, WA
Medical Insurance Billing & 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.

Presented lesson plans using exhibits, audiovisual equipment, Computers & the Internet/Web.

Developed daily lesson plans, advised and tutored students, take attendance and grade tests/records.
Participated in faculty meetings, Student functions, Graduation exercises, and new student orientation.


Insurance Overload Staffing
Renton, WA
Practice Management Software Implementation
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.

Assign Level II HCPCS Coding for Medicare & Medicaid patient Ambulance Services or Durable Medical Equipment.


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 Medicaid Oncology (Epoetin) claims in 68 Business days.

Call patients on outstanding balance, and if necessary, setup payment plan in hopes of securing payment.

Gather supporting documentation and file appeal with insurance based on factual benefit information.

Significantly decreased standard claim payment turnaround time by efficiently managing claims and taking advantage of the payer's online claims adjustment and re-submittal system/portal.

Education, Training - Systems Experience

American Medical Billing Association
Medical Reimbursement Specialist Credentialing/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

Quickbooks Pro

Microsoft Office Programs

Medical Claims Adjudication Class

Meditech Practice Mgmt Software

Premis Patient Accounting Software

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  • do NOT contact me with unsolicited services or offers

post id: 7044117285



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