Dale Marquez

DALE MARQUEZ Quezon City, Philippines | - |- SUMMARY Skilled in managing claims denials, coordinating the ordering and purchasing of medical equipment, and scheduling surgeries and various medical appointments. Experienced professional skilled in managing claim rejections, appeals, and unpaid claims. Proficient in using Salesforce CRM, as well as with CPT, ICD-10, HCPCS codes, CMS-1500, and UB-04 forms. Expertise in benefits verification, prior authorizations, referrals, and coordinating the ordering and purchasing of medical equipment. Adept at scheduling surgeries and various medical appointments. Committed to meeting targets and providing outstanding client support. Claims Management: Experienced in managing Denials, Rejections, Unpaid Claims, Grievances, and Accounts Receivable (AR) Follow-ups, with expertise in Appeals & Grievances Management, Eligibility & Prior Authorization Verification, Issue Resolution, Conflict Management, Quality Assurance, and Process Improvement. Proficient in using Salesforce CRM, as well as with CPT, ICD-10, HCPCS codes, CMS-1500, and UB-04 forms. Skilled in managing the ordering and purchasing of medical equipment, as well as scheduling surgeries and various medical appointments. Managed 20-50 daily claims-related emails, ensuring timely, professional responses and effective issue resolution. Prioritized, categorized, and maintained clear communication while following up to ensure customer satisfaction. Committed to meeting targets, improving processes, and delivering exceptional client support. Communication & Support: Proficient in active listening, fostering empathy, building strong client relationships, optimizing response times, ensuring clear communication, and executing effective follow-ups. Tools & Platforms: Salesforce, Availity, Adobe Acrobat, Microsoft 365, Microsoft Excel, Outlook, Gmail, EMR, EHR. Scheduling & Coordination: Skilled in scheduling surgeries and various medical appointments, ensuring efficient coordination between patients, healthcare providers, and medical teams. Proficient in ordering and purchasing medical equipment, ensuring timely delivery and proper documentation. Experienced in verifying eligibility, managing prior authorizations, and maintaining clear communication with patients and providers to ensure smooth operations and customer satisfaction. Professional Competencies: Attention to Detail, Time Management, Problem Solving, Conflict Resolution, Team Leadership, Multi-tasking in High-pressure Environments, and Handling Sensitive Information with Confidentiality. Professional Experience NTT DATA SERVICES 2019 – 2023 Customer Senior Representative, (Full-Time) ● Skilled in understanding and addressing claim denials, rejections, and unpaid claims across various insurance providers, ensuring efficient resolution and minimizing revenue loss. ● Managed 50–60 daily calls with 98% accuracy, assisting members with claim denials, appeals, and benefit-related inquiries. ● Proficient in using insurance portals such as Availity, Cigna, and AvMed to research, resolve, and prevent claim denials effectively. ● Experienced in handling CPT, ICD-10, and HCPCS codes and utilizing forms like CMS-1500 and UB-04 to ensure accurate claim submissions and compliance with payer requirements. ● Verified eligibility, prior authorizations, and referrals to prevent claim issues and address member concerns proactively. ● Consistently deliver exceptional customer service in high-pressure environments, achieving KPIs and monthly goals related to claim resolution and customer satisfaction. ● Skilled in using Salesforce CRM for tracking claim cases, ensuring accurate data entry, and assigning cases for timely follow-ups. ● Proficient in Adobe Acrobat for efficient handling of claim-related documents, including editing, secure file management, and submission preparation. COOL BLUE VA - 2024 Insurance verifier and Billing representative (Full-Time) • • • • • • • • Verified patient insurance eligibility for a wide range of health plans, ensuring accurate and timely processing of claims. Coordinated with insurance providers to confirm coverage details, benefits, and preauthorization requirements for various medical services. Processed patient billing inquiries and worked with insurance companies to resolve discrepancies in claims and payments. Checked patient payment responsibilities prior to office visits, providing accurate cost estimates and confirming any outstanding balances. Added pending balances to patient bills, ensuring all previous charges were accounted for in their current billing statement. Maintained up-to-date patient insurance information in the system, ensuring accuracy for future claim submissions and verifications. Managed prior authorization requests for medical procedures, ensuring timely approvals and avoiding delays in patient care. Handled patient billing disputes and appeals, collaborating with insurance carriers to facilitate accurate claim resolution. MEDIDESK- Purchasing Coordinator | Scheduler | Surgical Coordinator (Full-Time) • • • • • • Purchasing & Supply Management: Oversee the procurement process, ensuring timely ordering and availability of medical supplies and equipment. Act as the primary point of contact for vendors, managing purchase orders (POs), and verifying that all supplies are accurately billed and delivered on time. Billing Oversight: Ensure that all supplies, equipment, and services are correctly billed, maintaining accurate records for both internal and external use. Collaborate with the billing department to resolve discrepancies and streamline billing processes. Surgical Coordination: Manage the scheduling of surgeries, working closely with surgeons, medical teams, and patients to ensure seamless operation. Confirm that all pre-operative requirements are met, including medical clearances, necessary documentation, and patient consent forms. Patient Documentation & Compliance: Review patient records to ensure all required documents, including medical clearances, lab results, and pre-surgical instructions, are completed before surgery. Facilitate communication between patients, medical teams, and insurance providers to ensure compliance with health plan guidelines. Appointment Scheduling & Coordination: Effectively manage patient appointment schedules for surgeries, pre-operative consultations, and follow-up visits. Ensure that all stakeholders, including patients, surgeons, and medical staff, are informed of scheduled times and any changes. Cross-functional Collaboration: Collaborate with medical, administrative, and insurance teams to ensure the smooth coordination of patient care and surgical procedures. Facilitate the coordination of pre-operative tests and ensure that all necessary approvals and authorizations are in place.