Olivia Morgan
Philadelphia,PA
Summary
Skilled in handling complex insurance claims and policy processing with experience in navigating through various insurance software systems. Demonstrates strong analytical skills, adept at interpreting policies and efficiently resolving claims to the satisfaction of all parties involved. Known for maintaining high accuracy levels in document processing and data entry, contributing to streamlined operations and improved customer service outcomes. Continuously seeks ways to optimize workflows and enhance team productivity, leading to more efficient claim resolution processes.
Overview
11
11
years of professional experience
Work History
Supervisor, of Grievance & Appeals
AmeriHealth Caritas Family of Companies
04.2024 - Current
- Keep abreast of and abide by all applicable federal, state, and local laws as well as other rules (such as NCQA standards) pertaining to appeal and grievance procedures.
- Oversee and assist a team of 20 coordinators with the development and implementation of daily appeal phone and email procedures to ensure efficiency and compliance regarding completion of appeals.
- Responsible for correspondence compliance to stakeholders, and state bureaus pertaining to legal request and inquiries regarding appeals.
- Works in conjunction with appeals Legal department to also ensure contractual guidelines are followed regarding appeal audits, hearings, and documentation.
- Generated statistical reports for mitigating daily departmental and company risk pertaining to appeal compliance, projects, audits, using various analytical platforms.
- Host ongoing peer and technical on-the-job training for new hire and tenured employees in training groups of 12 regarding appeals systems, updates, procedures, and risk trends regarding appeals.
- Daily monitoring of employees and projects through various systems i.e Jiva, Facets and Tableau, Microsoft Office Suite (Excel, PowerPoint, Adobe Pro, Outlook), Virent
Team Lead, of Grievance & Appeals
AmeriHealth Caritas Family of Companies
03.2020 - 04.2024
- Carries out in-depth background investigation on research-related to grievances to assist in determination of appeal regarding Medicare and Medicaid health care programs.
- Provide senior leadership with daily reports detailing compliance concerns related to closed, open, and pending cases.
- Delegate appeals and grievances to staff to ensure the standard and expedited contract turnaround times are consistently exceeded per contract requirements.
- Organize adherence to legal requirements and requests for internal and external audits, collaborating with the corporate audit division as necessary.
- Acts as trusted advisor for staff escalation requests by maintaining a current working knowledge of appeals processing rules, contractual guidelines, plan policies and operational procedures.
- Analyzes the ongoing profitability of all new businesses and/or programs entered by the department.
- Address audits reports using Tableau and SQL systems to provide quality review feedback.
Grievance Appeals Coordinator
AmeriHealth Caritas Family of Companies
Philadelphia, PA
11.2019 - 03.2020
- Resolved provider and member claims, disputes, grievances, appeals, and hearing requests under Grievance System.
- Examined denial results and reported underlying data quality issues to management.
- Evaluated past authorization data for inclusion in departmental appeal documentation.
- Drafted detailed case summaries for appeals and submitted them for medical director evaluation.
Customer Service Lead
Lucky Vitamin
Conshohocken, USA
10.2017 - 08.2019
- Supervised about 20 in-person Customer Service Representatives with daily activities of call center to ensure phone queue and adequate email coverage.
- Monitored Customer Service Representatives’ phone calls to provide coaching and constructive feedback assisting with their professional development.
- Acted as a subject matter expert and an agent for the company's vitamins, supplements and alternative health products, shipping, and inventory policies for 20 coordinators.
- Managed all aspects of the call center's inbound and outgoing computer systems, including Outlook, ChatBot, ZenDesk, Lotus, and Aviva for live chat, e-mail, postal mail, and phone calls for 20 employees.
- Contributed to a well-coordinated operation, reducing downtime, improving customer service interactions, and ultimately optimizing the overall efficiency of the call center.
- Company acquired by Fruitful Yield family 2023
Customer Service Representative
Lucky Vitamin
Conshohocken, USA
05.2015 - 10.2017
- Establish connections and confidence with client accounts through open and interactive communication via chat, phone, email, postal mail.
- Respond to order issues, consumer complaints, offer suitable remedies and substitutes in a timely manner, and monitor the situation to make sure it is resolved regarding herbal supplement orders.
- Generate sales leads for herbal supplements while meeting monthly sales quota.
- Identify, assess, and assist with customers’ needs regarding herbal supplements and orders, to achieve customer satisfaction.
- Company acquired by Fruitful Yield family
Education
Bachelor of Science - Psychology
Capella University
Minneapolis, MinnesotaSkills
- Microsoft Outlook 360
- Tableau
- Chatbot development
- Zendesk support
- Lotus Notes
- Avaya communication
- SQL database management
- Excel spreadsheet analysis
- Jiva system navigation
- Facets interface management
- Salesforce CRM
- Perform RX software
- RadMD platform usage
- Python programming
- CSS styling techniques
- Virent system expertise
Timeline
Supervisor, of Grievance & Appeals
AmeriHealth Caritas Family of Companies
04.2024 - Current
Team Lead, of Grievance & Appeals
AmeriHealth Caritas Family of Companies
03.2020 - 04.2024
Grievance Appeals Coordinator
AmeriHealth Caritas Family of Companies
11.2019 - 03.2020
Customer Service Lead
Lucky Vitamin
10.2017 - 08.2019
Customer Service Representative
Lucky Vitamin
05.2015 - 10.2017
Bachelor of Science - Psychology
Capella University