Customer Service Patient

Dahlia Morgan

804-***-**** ***********@*****.*** Sandston, Virginia

CLAIMS RESOLUTIONS SPECIALIST

Knowledgeable and motivated medical billing professional with a strong background in claims resolution, customer service, and team leadership. Expertise in ICD-9/ICD-10 coding and Medicare/Medicaid policies. Demonstrated success at enhancing customer satisfaction, streamlining claims processes, and optimizing business operations. A results-driven leader dedicated to patient service and business success. SKILLS

Adaptability Administration Analytical skills Brightree CPT Coding Communication Critical thinking Customer service Data Entry Detail-oriented EPIC HIPAA HMA Imagine Interpersonal skills Macess Medical terminology Microsoft multi-tasking Patient Service Problem-solving Project management QNXT Quality assurance Webx Wintegrate PROFESSIONAL EXPERIENCE

Commonwealth Radiology, P.C./Data Practice Management, Inc., Richmond, VA Feb 2022 - Feb 2025 Claims Resolutions Specialist

Reviewed, researched, and reconciled carrier rejections and denials

Worked with third-party payors and insurance carriers to resolve unpaid claims

Identified and communicated with direct supervisor regarding trends and reimbursement issues

Prioritized work in accordance with established guidelines

Processed carrier mail/correspondence

Handled denial from refund request letters

Assisted with clearinghouse claim rejections

Ensured compliance with organizational policy and HIPAA regulations Virginia Premier Health Plan (Now Sentara Health Plan), Richmond, VA May 2018- Feb 2022 Claims Customer Service Representative III

Handled claims appeals, resolving issues within 30 days of receipt.

Handled all incoming requests for reconsideration for all lines of business with a goal of 80 per day

Identified trends in reconsideration requests by individual provider to share findings an ensure provider education to avoid future denials and claims re-work

Identified potential system issues and reported them

Handled miscellaneous duties/activities as directed by management Roberts Home Medical, Ashland, VA Jan 2007 - Nov 2017 Supervisor of Customer Service/Billing Representative, 2014 - 2017

Provided a consistently high level of customer service to internal and external customers

Ensured respectful and courteous resolution of customer inquiries, disputes and concerns

Supported sales/management by expeditiously and diligently researching and responding to customer inquiries, providing appropriate information about their accounts

Set clear expectations for CS staff to deliver excellent quality customer services by ensuring proper hiring, training, evaluation and leadership

Effectively communicated and delivered employee feedback and performance appraisals Dahlia Morgan ***********@*****.*** Page 2

Fostered a shared and common goal of quality service within the Company and cultivates long term trust and reliability of service with the customer

Built trusted and long-term relationships with referrals and vendors to ensure future sales growth and company profitability

Worked closely with RT, Dispatch, Billing and Warehouse staff to ensure fulfillment of home medical equipment orders, patient setups and coordinating delivery or pick-up of home medical equipment as needed

Administrative Team Lead, 2012 - 2014

Responsible for providing leadership for the customer service, billing, cash applications, respiratory therapy, and warehouse staff

Oversaw order entry, productivity levels, and phone monitoring, ensuring service standards were met and optimum services were provided

Generated monthly reports and ensured accuracy; handled escalated phone calls and complaints; solved problems and improved efficiency to ensure the department was functioning at the highest level of accuracy and productivity

Oversaw the verification of documentation for insurance coverage and performed timely billing and follow up to collect the outstanding accounts receivable

Led the billing department, including patient billing, collection activities, receivable adjustments, and computer operations; ensuring optimum reimbursement for medical services rendered, and for timely submission of all insurance claims and adjustments

Ensured the effectiveness of mail processing, bank deposits; posting payments, adjustments and denials; distributing correspondence and overpayment data

Oversaw daily cash application processes, monitored productivity, coache and trained department staff

Created and dispersed accurate daily, weekly and monthly reports; solved problems, streamlined workflows, performed audits and improved processes to ensure the department was operating at the optimal level of efficiency to meet all departmental and company goals and deadlines

Oversaw scheduling, reporting, and ensured daily operations were efficient and outstanding customer service was provided by all respiratory staff

Oversaw the warehousing of products, cleaning, and maintenance of equipment

Ensured that appropriate product levels were maintained Billing Specialist, Jan 2007 - Dec 2011

Prepared claims for submission to Medicare and/or Medicaid, third party insurers, and Managed Care Organizations

Responded to customer inquiries regarding Medicare denials and Medicare appeals status

Performed routine follow up on delinquent and underpaid claims and all patient pay accounts

Obtained medical chart documentation and diagnostic test results from physicians and other practitioners to validate that Medicare and other insurer billing requirements are met

Logged and tracked results of mandatory Medicare audits as required by the government contractors

Prepared, mailed, tracked, and maintained Certificates of Medical Necessity for Medicare, Medicaid, and Medicare Advantage accounts

Anthem Blue Cross/Blue Shield, Richmond Oct 2003 - May 2006 Customer Service Representative

Received inbound telephone calls or paper and electronic claims from members and providers

Resolved and responded to issues received through written or electronic communications

Resolved issues for members, providers, group administrators and brokers Dahlia Morgan ***********@*****.*** Page 3

Applied knowledge of benefits policies and procedures, product knowledge, legislation and claims workflow

Interacted with systems to ensure claims were paid or denied based on terms of contract

Interpreted claims to determine primary or secondary liability, recognizing when additional information was needed

Made decisions on claims payments while considering benefit status, provider status, and impact on Anthem, the provider, and the member

Health Insurance Plan of Greater New York, New York, NY May 1997 - June 2003

Claims CQI Analyst, 2001-2003

Reviewed, analyzed, and conducted pre- and post-payment audits for internal and external professional and facility claims

Audited claims for TPAs and IPAs to determine compliance with policies and procedures

Analyzed patient and medical information ensure claims were processed appropriately

Processed adjustments for previously paid or denied claims

Effectively communicated with senior management

Supervised a team of five on special assignment, reduced overload of correspondence and completed project within time and budget

Trained new Claims Examiners in point of service claim adjudication

Analyzed coordination of benefits (Workers' Compensation, No-Fault, etc.) Claims Examiner, 1997-2001

Priced claims by computer and manually, using a Q/Care System

Determined payment rates

Held sole processing responsibility for 2,000 claims, monthly

Utilized knowledge in medical terminology, using CPT and ICD/9 coding

Analyzed patient and medical information to identify coordination of benefits EDUCATION

LaGuardia Community College, Queens, NY

Business Track

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