Summary
Overview
Work History
Education
Skills
Awards
Work Availability
Timeline
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Cheryl Mills-Guiellmo

Elkins Park

Summary

Well-qualified Quality Control Inspector proficient in documentation, reporting and compliance standards. Meticulous and methodical professional with a deep understanding of medicare and medical claims production operations. Bringing 39 years of related experience. Experienced Quality Control Inspector skilled at inspections, assessments and reporting on medicare medical claims quality issues. Accomplished at helping claim department dramatically improve medical claims production through quality control enhancements. Works well with production teams on correcting negative trends and driving improvements.

Overview

39
39
years of professional experience

Work History

Working in the quality review department

United HealthCare
01.2009 - Current
  • Making sure ALL claims processed correctly
  • This entails all benefits sent to ours insured members, doctor’s offices and medical facilities sent to the correct payee
  • In regard to the doctor’s office and medical facilities, benefits must be paid to the provider correct Tax Id Numbers and NPI numbers.

Worked in Enrollment/Underwriting department

UnitedHealthcare
01.2019 - 01.2021
  • During open enrollment period

Worked in the centralized phone unit

United HealthCare
01.1999 - 01.2009
  • Resolving customers questions and issues involving their medical claim benefits and what services are covered under their policies
  • Make any corrections on claims and benefits which were incorrectly paid.

Claims Examiner

United HealthCare
07.1989 - 01.1999
  • Promoted three levels during tenure in the claims department
  • Specialized in the quality review department for the last thirty four years and demonstrated experience in handling and processing all medical claims such as pre-existing, private duty nursing, skilled nursing facilities, office visits claim
  • Review provisions of certificate or policy to determine the patient’s included medical coverage losses
  • Negotiate claim settlements and make recommendations for legal action when settlements are deemed non-negotiable
  • Complete logs, reports, forms and records to properly document medical claims
  • Reject or accept documentation, determine benefit due, and start the denial or payment process to resolve medical claims
  • Adhere to all company policies, procedures and guidelines in addition to insurance regulations at the federal and state level
  • Examine medical treatment records, and medical bills to gauge overall extent of liability Interview and Communicate with Claimants, Physician’s Offices and other necessary individuals to decide claim denial, settlement or review
  • Ensure all claims information remains confidential
  • Attained vast knowledge on processing medical claims by engaging in continuing education and training opportunities when possible.

Medical Claims Specialist

United HealthCare
09.1985 - 07.1989
  • Examine/process medical claims records and forms to determine patient eligibility for the AARP division of a medical insurer serving approximately 3.5 million members in the U.S., its territories and expatriates worldwide
  • Mail Room Clerk – Sorting and delivering mail - Incoming claims to the appropriate locations

Education

Bachelor of Business Administration - Human Resource Management

Fox School of Business, TEMPLE UNIVERSITY
01.2022

Skills

  • JAVIS
  • FOX (Furthering Operational Excellence)
  • KONNEX
  • GLOBAL PCH SOLUTIONS
  • UCPS
  • COMPAS
  • FASTRIEVE
  • MICROSOFT WORD AND EXCEL
  • CRITICAL EVALUATION
  • VISUAL INSPECTION

Awards

Excellence Customer Service for United Healthcare’s Centralized Phone Unit

Work Availability

monday
tuesday
wednesday
thursday
friday
saturday
sunday
morning
afternoon
evening
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Timeline

Worked in Enrollment/Underwriting department

UnitedHealthcare
01.2019 - 01.2021

Working in the quality review department

United HealthCare
01.2009 - Current

Worked in the centralized phone unit

United HealthCare
01.1999 - 01.2009

Claims Examiner

United HealthCare
07.1989 - 01.1999

Medical Claims Specialist

United HealthCare
09.1985 - 07.1989

Bachelor of Business Administration - Human Resource Management

Fox School of Business, TEMPLE UNIVERSITY

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Cheryl Mills-Guiellmo