Makayla Dunston
American Specialty Health
Henderson,NC
8
years of professional experience
Experienced Clinical Service Representative with over 7 years in healthcare customer service. Resolves complex eligibility and claim issues while effectively guiding providers and members through benefits, referrals, and pharmacy processes. Committed to enhancing access to care and improving satisfaction through detail-oriented, patient-focused communication.
Work History
Clinical Service Representative
9 Months- Managed a high volume of inbound calls from healthcare providers, members, and health plans while delivering exceptional customer service.
- Verified member eligibility and benefits and provided accurate information regarding coverage.
- Researched and resolved inquiries on claim status, ensuring clear communication of outcomes for denied, partially approved, reprocessing, and paid claims.
- Reviewed and communicated referral and authorization status to providers and members.
- Reviewed and communicated referral and authorization statuses to providers and members, facilitating timely patient care.
- Resolved complex issues by researching account information, documenting interactions, and ensuring timely follow-up.
- Guided providers in submitting medical-necessity documentation via the Ashlink portal or by fax, ensuring compliance with submission protocols.
- Consistently demonstrated professionalism, accuracy, and strong problem-solving skills in a fast-paced call center environment.
- Supported provider offices with credentialing and enrollment inquiries.
- Utilized appropriate resources, including those online, to provide timely responses.
Customer Service Representative
10 Months- Delivered exceptional customer service by assisting members, providers, and health plans with healthcare benefits, coverage, and account inquiries.
- Assisted members in ordering prescription medications and verified coverage under pharmacy benefits, ensuring access to necessary treatments.
- Completed benefit verifications and explained member eligibility, coverage, copays, deductibles, and out-of-pocket costs.
- Reviewed and explained formulary information, guiding members through preferred and non-preferred medications and available coverage alternatives.
- Coordinated prescription requests by sending providers notifications for new prescriptions or prescription renewals.
- Researched and resolved inquiries related to claims, referrals, authorizations, and provider services while ensuring timely issue resolution.
- Navigated CRM, Salesforce, and Slack to manage customer interactions, document case details, and collaborate with internal teams.
- Maintained accurate documentation of customer interactions while ensuring HIPAA compliance and adherence to healthcare regulations.
- Demonstrated strong communication, problem-solving, and multitasking skills in a fast-paced healthcare call center environment.
- Analyzed customer concerns to identify improvement opportunities, leading to enhanced service quality and operational efficiency.
- Collaborated with cross-functional teams to improve workflows, resulting in increased productivity and improved customer satisfaction.
Customer Service Representative – Pharmacy Benefits
2 Years 6 Months- Handled 60–200 high-volume inbound and outbound calls daily, assisting members with prescription benefits, insurance coverage, and pharmacy-related inquiries.
- Educated members on copays, deductibles, pharmacy networks, formulary coverage, and replacement ID card requests.
- Processed mail-order prescription refills and coordinated medication orders with participating pharmacies.
- Completed benefit verification for retail and specialty medications, confirming eligibility, coverage, and prior authorization requirements.
- Reviewed and processed prior authorizations, step therapy requirements, and appeals based on health plan criteria, communicating approval or denial decisions to members and providers.
- Assisted members with Medicare, Medicaid, Managed Care, and Commercial insurance plans by explaining pharmacy benefits, claims, and coverage options.
- Interpreted and explained Explanation of Benefits (EOBs), claim status, and member cost-sharing responsibilities.
- Resolved complex member and provider issues, enhancing first-call resolution and increasing customer satisfaction.
- Collaborated with cross-functional teams to streamline communication and optimize workflow efficiency in service delivery.
- Analyzed customer feedback and identified trends to drive continuous process improvements and operational excellence.
- Built positive relationships with members and providers through effective communication, empathy, and problem-solving.
- Maintained strict compliance with HIPAA regulations and company policies while protecting confidential patient information.
Prior Authorization Specialist
1 Year- Reviewed prior authorization requests to verify medical necessity, benefit eligibility, and health plan requirements.
- Verified member eligibility, benefits, and authorization requirements for Medicare, Medicaid, Commercial, and Workers’ Compensation plans.
- Investigated denied claims and prior authorization denials, identified root causes, and resubmitted eligible requests with appropriate documentation to facilitate approvals.
- Explained authorization decisions, claim status, and insurance terminology to members, providers, and healthcare facilities.
- Assisted providers with submitting prior authorizations, appeals, and supporting clinical documentation to facilitate timely determinations.
- Investigated denied claims and prior authorization denials, identified root causes, and resubmitted eligible requests with supporting documentation.
- Maintained accurate documentation of prior authorization requests, appeals, claim activity, and member communications while ensuring HIPAA compliance.
- Collaborated with cross-functional teams to resolve authorization and claims issues, enhancing communication and reducing processing delays.
- Analyzed authorization and claims trends to identify process improvement opportunities, contributing to better quality initiatives.
- Delivered exceptional customer service by resolving complex authorization and claims inquiries while meeting productivity and quality standards.
Data Entry Specialist
6 Months- Facilitated application entry for managed care to ensure efficient processing.
- Handled managed care applications through multiple channels to streamline workflows.
- Ensured that all data was entered accurately with no errors in the system.
- Entering information from fax to enroll member in Managed Care plan.
- Maintained strict HIPAA compliance and managed confidential records.
- Conducted claim research and updated records based on supporting documentation.
- Resubmitted denied claims with accurate coding for faster adjudication.
- Collaborated with team members to streamline data processes, fostering a culture of efficiency and shared success.
- Maintained organized records and documentation, ensuring compliance with data management protocols for improved access and retrieval.
- Reduced errors in data records by conducting thorough quality checks and implementing corrective measures.
- Corrected data entry errors to prevent later issues such as duplication or data degradation.
- Maintained files, records, and chronologies of entry activities.
- Updated and maintained customer information, documents and records.
- Managed and organized documents for data entry tasks.
Customer Service Representative
7 Months- Transferred incoming calls and chats to appropriate departments.
- Executed test claims to provide members with accurate medication pricing information.
- Identified and shared information about in-network and out-of-network pharmacy options with members.
- Assisted members in the step-by-step process of accessing their Aetna accounts and plan information online.
- Refilling mail-order prescriptions.
- Running test claims for estimated prices for medications.
- Recognized patterns of inconsistent and/or inaccurate claims filing and billing practices among customers and providers.
- Called other insurance companies and healthcare physicians on behalf of members per the company.
- Handled incoming communications via chat, call, and email from members, providing timely assistance.
- Adhered to HIPAA policies and protocols, becoming HIPAA certified.
- Communicated with other insurance companies and healthcare physicians to support member inquiries.
- Identified patterns of inconsistent and inaccurate claims filing and billing practices, contributing to improved accuracy in claims processing.
Education
High School Diploma
Skills
Data Entry
Active Listening
Appointment Scheduling
Benefit verification
Prior authorization
Time management
Multitasking proficiency
HIPAA compliance
Data entry
Insurance authorizations
Electronic medical records
Patient relations
Customer service
Claims review
Accuracy and precision
Claims processing
Timeline
Clinical Service Representative
American Specialty Health
09.2025 - 06.2026Read More
Customer Service Representative
Everise
10.2024 - 08.2025Read More
Customer Service Representative – Pharmacy Benefits
Alorica
04.2022 - 10.2024Read More
Prior Authorization Specialist
ResultsCX
05.2021 - 05.2022Read More
Data Entry Specialist
Randstad
11.2020 - 05.2021Read More
Customer Service Representative
Conduent
06.2018 - 01.2019Read More
Northern Vance High School
High School Diploma
Read More