Tanya Morning
Fuquay-Varina
Summary
Detail-oriented Appeals Nurse with 15+ years of experience in revenue cycle management and clinical validation. Proven track record in writing successful appeals for denied claims, leading teams, and conducting audits to enhance operational efficiency. Expertise in ICD-10, CPT coding, and utilizing clinical decision-making to recover revenue.
Skilled in handling complex insurance claims and policy processing with experience in navigating through various 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
18
18
years of professional experience
1
1
Certification
Work History
Appeals nurse Clinician RN
Aergo Health Solutions
New Jersey
10.2021 - Current
- Reviewing medical records against nationally recognized clinical criteria guidelines (Interqual, MCG, NCD/LCD,DCA, etc.)
- Writing professional appeals in response to denied claims such as medical necessity appeals, RAC, PPA and DRG downgrades.
- Use of CPT, ICD-10 and DRG
- Identifying the root cause for clinical claim denial
- Use of EPIC and Meditech
- Reviewed and validated insurance claims for compliance with regulations.
- Collaborated with healthcare providers to ensure accurate coding and documentation.
- Audited revenue cycle processes to identify areas for improvement.
- Processed appeals related to denied or rejected claims in a timely manner.
- Reviewed patient accounts to ensure accuracy and completeness of information.
Medicare Tech Billing Nurse
Johns Hopkins Health System
Baltimore
10.2022 - 06.2025
- Reviewing medical records against nationally recognized clinical criteria guidelines (NCD/LCD,DCA, etc.)
- Charge Audits
- Use of ICD 10/ CPT codes
- Clinical Validation audits
- Using clinical decision-making to determine the appropriate actions needed to recover or defend revenue for high-dollar claims
- Writing professional appeals in response to denied claims or payer audit requests
- Assisted external auditors during annual audits by providing requested documentation, explaining accounting processes, and addressing inquiries
- Collaborated with healthcare teams to ensure compliance with utilization review standards.
- Communicated findings effectively to providers and insurance companies.
- Developed and updated utilization review policies to align with regulations.
- Analyzed data trends to identify opportunities for process improvements.
- Supported quality assurance initiatives by auditing case reviews for accuracy.
- Assessed patient medical records to determine the appropriateness of requested services and procedures.
- Served as a resource for staff members seeking guidance on utilization review matters.
- Applied medical criteria and clinical judgement to researched cases to evaluate and establish determinations.
- Maintained up-to-date knowledge of health plan benefits, policies, procedures, regulations, coding guidelines.
- Provided education to providers regarding utilization management processes and protocols.
- Reviewed denial letters issued by insurance companies to ensure that they were appropriate and timely.
- Collaborated with staff members in group meetings to identify issues and find cost-effective solutions.
- Generated reports related to utilization management activities such as length of stay trends, denials rates.
Appeals Denials Nurse/Team Lead
Ensemble Health Partners
06.2019 - 10.2021
- Identifying the root cause for denied claims
- Using clinical decision making to determine the appropriate actions needed to recover or defend revenue for high dollar claims
- Writing professional appeals in response to denied claims or payer audits
- Team Mentor
- Identifying and reporting trends to remediate issues and assist with internal process improvement
- Trained new staff on revenue cycle best practices and procedures.
- Processed appeals related to denied or rejected claims in a timely manner.
- Maintained current knowledge of insurance policies, procedures, regulations, and guidelines.
- Conducted quality assurance audits to maintain high standards of clinical reviews.
Clinical Quality Team Lead
Primaris
Columbia
12.2017 - 06.2019
- Supervised a team of seven quality data abstractors for an acute care quality data review.
- Primary contact for quality data services provided by Primaris.
- Conducted weekly meetings with client management.
- Delegated tasks and set deadlines per client completion.
- Monitored team performance (IRR) on medical abstraction and reported on metrics.
- Multi EMR use and setup for a large ACO.
- Led quality assurance processes to ensure compliance with industry standards.
- Conducted regular audits to evaluate adherence to quality protocols.
- Facilitated team meetings to discuss quality performance and improvement areas.
- Drafted presentations highlighting key findings from Quality Assurance activities.
- Implemented, maintained and verified compliance to various international quality standards and administered training on standards.
Medicare Appeals Nurse Specialist III
C2C Innovative Solutions Jacksonville FL
Jacksonville
12.2015 - 08.2017
- Review of Medicare Reconsideration Appeals for a Government contract (Payer)
- Review of requests of a written reconsideration of Medicare (Part A) or (Part B) appeal.
- Medical necessity review of items and services based on LCD's, NCD's and PIM.
- Provided verbal and written education for the reason of denial of appeal to providers and suppliers.
- Completion of time sensitive projects.
- Held recorded Formal Phone Discussion related to the reconsideration based on Medicare's guidelines, to help reduce the backlog of claims at the Medicare ALJ level.
- Written reconsideration appeal decision that is clear and supports the determination made. Makes sound, independent decisions based on medical evidence in accordance with statutes, regulation, rulings, Centers for Medicare & Medicaid Services (CMS) policy, and local policy.
- Reviewed patient cases to determine appropriate levels of care and services.
- Assessed patient medical records to determine the appropriateness of requested services and procedures.
- Served as a resource for staff members seeking guidance on utilization review matters.
- Applied medical criteria and clinical judgement to researched cases to evaluate and establish determinations.
- Maintained up-to-date knowledge of health plan benefits, policies, procedures, regulations, coding guidelines.
- Provided education to providers regarding utilization management processes and protocols.
Medical Review Nurse
83 Bar
Austin
10.2015 - 04.2016
- Telephonically review of medical information to clients.
- Make or refer to specialty appointments.
- Health promotion and customer service.
Administrator
Morning Academy
NC
08.2011 - 09.2015
- Developed Teaching plan for students.
- Prepared reports for our facilitator to review progress.
- Researched and select appropriate resources.
- Developed individual study plans for students working at different levels.
Appeals Nurse Specialist
Blue Cross Blue Shield NC
Chapel Hill
01.2008 - 08.2011
- Appeals of denied services such as Inpatient admissions, length of stays, and surgical claims. (Payer side)
- Determined medical necessity of the requested services or treatment.
- Use of Millimans care guidelines, Medical policy, and Medicare guidelines to approve or deny claims.
- Completion of time sensitive projects.
- Nursing resource for non-clinical staff.
- Daily telephone/electronic communication with Providers and Members.
- Assessed patient medical records to determine the appropriateness of requested services and procedures.
- Evaluated clinical documentation for accuracy and completeness in order to make decisions about coverage determinations.
- Served as a resource for staff members seeking guidance on utilization review matters.
- Applied medical criteria and clinical judgement to researched cases to evaluate and establish determinations.
Education
Bachelor's degree - BSN
Post University
Associate in Science (AS) - General Studies
Hutchinson Community College
Diploma - Nursing
CT State Vocational Bullard Havens
Skills
- Clinical documentation
- Medical necessity review
- Revenue cycle management
- Appeals writing
- Utilization review
- Microsoft Office
- Excel
- Quality assurance
- Slicer Dicer
- Data analysis
- Healthcare collaboration
- Problem solving
- Effective communication
- Team leadership
- Detail orientation
- Clinical judgment
- Medical coding
- Clinical auditing
- Claims management
- Revenue recovery
- Process improvement
- Denial management
- Medical billing
- Claims review
- Time management abilities
- Data trending
- Microsoft teams
- Appeal writing
- Medical necessity validation
Certification
- CRCR, Present
- RN License, Compact State Nurse License
Personal Information
Authorized To Work: US
Timeline
Medicare Tech Billing Nurse
Johns Hopkins Health System
10.2022 - 06.2025
Appeals nurse Clinician RN
Aergo Health Solutions
10.2021 - Current
Appeals Denials Nurse/Team Lead
Ensemble Health Partners
06.2019 - 10.2021
Clinical Quality Team Lead
Primaris
12.2017 - 06.2019
Medicare Appeals Nurse Specialist III
C2C Innovative Solutions Jacksonville FL
12.2015 - 08.2017
Medical Review Nurse
83 Bar
10.2015 - 04.2016
Administrator
Morning Academy
08.2011 - 09.2015
Appeals Nurse Specialist
Blue Cross Blue Shield NC
01.2008 - 08.2011
Bachelor's degree - BSN
Post University
Associate in Science (AS) - General Studies
Hutchinson Community College
Diploma - Nursing
CT State Vocational Bullard Havens