Shquria Sumter
Port Wentworth
Summary
Insurance professional with experience as a Life Claims Analyst, providing accurate and compassionate support to families while navigating complex claims and benefit determinations. Currently pursuing continued growth within the life insurance field to deepen knowledge in financial protection and long-term planning. Dedicated to integrity, professionalism, and clear communication.
Overview
5
5
years of professional experience
2020
2020
years of post-secondary education
1
1
Certification
Work History
Life Claims Analyst
Mutual Of Omaha
Omaha
07.2024 - Current
- Determines complex claim benefits based on medical records and contract language, ensuring timely decisions for both payment and denial.
- Analyzes and processes complex claims, communicates effectively with external and internal customers, and finalizes claims while explaining handling procedures.
- Provides effective customer service through various channels, using expanded knowledge and resources to resolve inquiries and perform service recovery techniques.
- Meets/exceeds department standards for attendance, productivity, and quality, while actively participating in daily management, contributing insights for process improvements.
Medical Claims Specialist
ResultsCx
Winter Haven
02.2023 - 05.2024
- Investigating and processing healthcare claims, including dental and vision adhering to HIPAA regulations.
- Communicate with members providers and other stakeholder regarding claims status, benefits and payments information.
- Identify and resolve claims discrepancies, errors and potential fraud and escalating to team leaders if needed.
- Monitoring and managing work volume to ensure efficient and timely claims processing.
Customer Service Representative
ResultsCx
Winter Haven
08.2021 - 04.2023
- Respond to high volume of customer inquiries via phone, email and chat regarding health insurance plans, benefits and claims in a professional timely manner.
- Stay up to date with industry developments, regulatory changes and companies policies to Informed support.
- Meet or exceed customer service performance metrics(E.g First Call Resolution, Customer Satisfaction, Adherence and Attendance)
- Document customer interactions and maintain accurate records in the system.
- Empathetically handle each call with sensitivity or complex customer situations and escalating to the appropriate team as needed.
Education
Winter Haven High School
Winter Haven, FloridaSkills
- Death & Medical Claims Processing
- Policy & Contract Interpretation
- Regulatory Compliance (HIPAA & Insurance Guidelines)
- Claims Investigation & Documentation Review
- Benefit Determination
- Fraud Detection & Escalation Procedures
- Customer Communication & Conflict Resolution
- High-Volume Case Management
- Confidential Data Handling
Certification
- Life Insurance Agent – State of Georgia
Timeline
Life Claims Analyst
Mutual Of Omaha
07.2024 - Current
Medical Claims Specialist
ResultsCx
02.2023 - 05.2024
Customer Service Representative
ResultsCx
08.2021 - 04.2023
Winter Haven High School