JOHN RAY GOMEZ
Bayambang
Summary
Experienced professional in the US healthcare industry adept at handling claims, benefits, prior authorization, and appeals. Skilled in maintaining quality care and ensuring accurate documentation for exceptional healthcare services. Strong collaborator, fostering cohesion and efficiency across departments.
Overview
12
12
years of professional experience
1
1
Certification
Work History
Post Pay Non-Clinical Investigator
United Health Group Global Services (Optum)
09.2018 - Current
- Provide expertise claims support by reviewing, researching, investigating, negotiating, and resolving all types of claims as well as recovery and resolution for health plans, commercial customers, and government entities
- Analyze and identify trends and provides reports as necessary
- Ensure adherence to state and federal compliance policies, reimbursement policies, and contract compliance
Clinical Specialist
Forta Health
04.2018 - Current
- Complete QA review of session notes completed by the BCBA before billing them to different insurance companies
- Prioritize and manage an undetermined capacity of clients for QA reviews, ensuring timely and thorough assessments
- Keep a meticulous record of daily QA outreach activities, tracking responses from relevant stakeholders
Staff Nurse
Nuestro Señor Santo Niño Hospital, Inc.
04.2022 - 09.2022
- Plan and implement patient care plans
- Collaborate with the patient care team to yield positive patient outcomes
- Assess and plan courses for patient care
- Ensure compliance with prescribed standards of practice
Provider Data Outreach Specialist
LizardBear Tasking Inc. (TaskUs)
09.2016 - 02.2018
- Verify provider information through outbound calls and web research
- Specialized in researching healthcare affiliated doctors’ profiles, confirming availability, and scheduling appointments via outreach calls
Benefit and Claims Associate
United Health Group Global Services (Optum)
11.2012 - 04.2016
- Assisting providers with Claims Status and Benefits
- Assisting providers in securing prior authorization
Education
Bachelor of Science - Nursing
UNIVERSITY OF PANGASINAN
Dagupan, Province Of Pangasinan, Philippines04-2011
Skills
- Detailed report writing
- Due diligence
- Ethical and honest
- Investigation management
- Data review
- Calm in crisis situations
- Report generation
Certification
- HIPAA Certified
- Six Sigma Certification
- CPR/AED Certification
Languages
English
Bilingual or Proficient (C2)
Estonian
Timeline
Staff Nurse
Nuestro Señor Santo Niño Hospital, Inc.
04.2022 - 09.2022
Post Pay Non-Clinical Investigator
United Health Group Global Services (Optum)
09.2018 - Current
Clinical Specialist
Forta Health
04.2018 - Current
Provider Data Outreach Specialist
LizardBear Tasking Inc. (TaskUs)
09.2016 - 02.2018
Benefit and Claims Associate
United Health Group Global Services (Optum)
11.2012 - 04.2016
- HIPAA Certified
- Six Sigma Certification
- CPR/AED Certification
Bachelor of Science - Nursing
UNIVERSITY OF PANGASINAN
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