Customer Service Quality Assurance

Thelma Sturghil-Johnson

**** * ****** *** *** Vegas, NV 89102 702-***-**** 708-***-**** ***************@*****.***

CAREER GOAL

Seeking a challenging career opportunity utilizing my multifaceted healthcare skills.

SKILLS & ABILITIES

Medical and Dental Terminology

Medical and Dental Coding

Customer Service (inbound and outbound)

Written Correspondence/Grievance and Appeals

Claims Inquiries

Quality Assurance

Medicare Parts A B D

SOFTWARE

Microsoft Word/Microsoft Excel/Microsoft Outlook

AS400 Claims Based System/ASA Claims System

Rims Claims System/CICS Claims System

ISSI System

EXPERIENCE

Dental Claims Processor 2012-2014

Fringed Benefits Local 150 Engineers Union Countryside,IL

. Responsible for investigating and resolving claims for self –funded plans

by utilizing the claims system.

Medical Claims Processor 2010-2012

North American Medical Management (Temp Agency) Lombard, IL

• Responsible for investigating and resolving Medicare Claims Parts A B D by utilizing the claims

systems in the areas of Managed Care Claims.

Claims Inquiry Analyst 2003 - 2010

Humana/Comp Benefits Corporation Chicago, IL

• Claims Inquiry Analyst: responsible for investigating and resolving claims inquiry issues from

various member service locations by utilizing the claims system and call center operation service

in the areas of Managed Care,Indemnity, PPO, Specialty and Major Account Claim processing.

• Team Administrator: responsible for contacting the Provider Specialist and Plan Building,

Eligibility Specialist for modification and confirmation for information needed to resolve and

inquiry issue.

• Claims Adjuster III: responsible for on-line processing of Managed Care Claims PPO,

Orthodontia, National Claims processing of group dental claims in accordance with plan

provisions and established corporate protocols.

Dental Health Maintenance Claims Unit Supervisor 1996 – 2003

Dental Network of America/Health Care Services Corp Oakbrook Terrace, IL

• Responsible for the day-to-day supervision and operation of the Managed Care Claims

Department consisting of 15-20 employees

• Maintained the department quality control program utilizing established corporate protocols and

procedure guidelines.

• Primary responsibilities included assisting and training new and existing claims personnel on

departmental guidelines and procedures, and the development and maintenance of procedural

manuals.

• Weekly quality and performance feedback of subordinates.

Senior Managed Care Dental Claims Examiner

• Responsible for reviewing and processing Managed Care Claims for an multiplicity of employer

groups for proper payment and determination utilizing plan provisions and corporate protocols as

well as performing other duties and projects assigned by department manager.

EDUCATION & PROFESSIONAL DEVELOPMENT

• Bryman School of Dentistry

• Jones Commercial High School

• Dental Assistant Certificate

• CPR Certificate

• Query 400

• :High Impact Communication Skills

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