Quality Assurance Customer Service
Resume:
Jessie Gomez
Albuquerque, NM *****
******.***********@*****.***
Professional Summary
Accomplished Quality Assurance Specialist with 29 years of experience in healthcare, customer service, and administrative roles. Proven track record in patient care, medical billing, and insurance verification. Skilled in leadership, team management, and quality audits. Proficient in Epic, Microsoft Office, and Google Suite. Possesses a strong understanding of medical terminology and HIPAA regulations. Bilingual in Spanish and English.
Authorized to work in the US for any employer
Work Experience
Quality Assurance Specialist
Ambercare Home Health & Hospice-Albuquerque, NM
September 2024 to December 2024
• Developed and implemented quality assurance policies, procedures, and standards to ensure compliance with industry regulations
Document Control Specialist/Medical Biller/DME Benefits Coordinator Omnisleep-Albuquerque, NM
June 2021 to May 2024
Responsible for following up on denied claims, submitting medical records to insurance companies for review, and/or submitted appeals. Assisted patients with processing payments on their accounts. I was responsible for verifying the patients insurance, deductibles, OOP, coinsurances, and verifying if an authorization is needed for the setup of CPAP equipment and supplies. If necessary I would submit the written prescription, medical records and and other clinical notes to insurance for review. Once the necessary authorization was obtained I would write up the estimated benefits sheets with the patient cost share, and approve the release and setup of CPAP equipment with the patient. I would collect, scan, and update any medical documents to the correct patient chart. I checked and edited documents for accuracy and compliance so the billing team could submit to insurance for processing. I controlled the flow of documents in and out of the department, as well as maintained the security of confidential documents.
• Maintained confidentiality of sensitive information contained in the documents handled
• Ensured compliance with regulatory requirements related to documentation within the industry sector
(e.g., ISO standards)
• Ensured compliance with document retention policies and procedures
• Performed quality checks on outgoing documents to ensure accuracy, consistency, and adherence to company standards
• Verified patient insurance coverage and obtained necessary authorizations for medical procedures
• Processed medical claims and invoices for a high-volume healthcare facility, ensuring accuracy and adherence to billing guidelines
• Reviewed and corrected coding errors on claims to maximize reimbursement from insurance companies
• Utilized electronic health record (EHR) systems to input patient information, update billing records, and generate reports
• Followed up with insurance companies regarding claim denials or discrepancies, resolving issues in a timely manner
• Collaborated with healthcare providers to obtain missing documentation or clarification on medical procedures for accurate billing
• Maintained strict confidentiality of patient information in compliance with HIPAA regulations
• Developed strong relationships with insurance company representatives to facilitate smooth claims processing and resolve any disputes or delays
• Maintained confidentiality and integrity in handling sensitive benefits-related information, ensuring compliance with privacy regulations
Patient Account Representative
Lovelace Health Systems-Albuquerque, NM
December 2019 to June 2021
Responsible for working A/R collection opportunities on unpaid claims through provided analytic reporting. Update and document financial data, utilizing excellent customer service skills to contact patients and insurance carriers to ensure accurate reimbursement. Handles incoming calls 50-70 a day. Works small dollar credits $100.00 and below, bankruptcy, and process patient payments. Insurance Follow-Up/Denials -50 per day. Billing Claims- rotate monthly in Batching claims for SSI, work SSI claims daily to ensure that all claims get billed. Work EPIC claim work queues and Account work queues daily, work 60 accounts daily, respond to emails sent by various Depts. in a timely manner.
Claims Technician
Blue Cross Blue Shield of NM-Albuquerque, NM
November 2017 to December 2019
I was responsible for processing complex claims requiring further investigation, including coordination of benefits and resolving pended claims. I was often times given projects to complete at the direction of my direct supervisor.
Provider Phone Representative
United Healthcare-Albuquerque, NM
January 2016 to November 2017
Answer incoming phone calls from health care providers (i.e. physician offices, clinics) and identify the type of assistance the provider needs (i.e. benefit and eligibility, billing and payments, authorizations for treatment and explanation of benefits (EOBs). Focus on resolving issues on the first call, navigate through the appropriate computer system(s) to identify the current status of the issue and provide appropriate response to caller. Deliver all information and questions in a positive, conversational and compassionate manner to facilitate developing a relationship with the provider, while providing the best customer service experience possible. Complete the documentation necessary to track provider issues and facilitate the reporting of overall trends. Meet the performance goals established for the position in the areas of: efficiency, call quality, provider satisfaction, first call resolution and attendance. Health Plan Customer Service Representative
Presbyterian-Albuquerque, NM
March 2013 to October 2015
Responds to questions or issues from PHP members and providers about insurance benefits, coverage, or premiums (Centennial Care, Commercial, IBAC, Medicare) with regard to: eligibility and demographic changes; ID card request and issuance; PCP assignments and changes; eligibility, terms and conditions, with respective benefit plan. Respond to incoming calls routed through skill-based technology to meet quality standards and performance measurements. Is ready to take calls at the scheduled time, and spends the appropriate amount of time taking calls throughout their shift to resolve contacts on initial encounter. Conducts outbound calls as required and meets established quality/quantity guidelines supporting PHS/PHP/PMG initiatives and/or programs. Develop and maintain positive customer or partner relationships. Acted as member/patient advocate in dealing with practitioners, employer groups, and brokers. Maintains prescribed standards of quality in all research, customer and partner contacts/ service functions and promotes customer satisfaction/loyalty through quality contact and timeliness of responses, achieves quality audit results as required. Participates and represents PHS/PHP in outreach events to include, but not limited to enrollment fairs, site visits, health fairs, job fairs, Member Focus Groups, Provider Information Sessions,
Provider Focus Groups and ANOC meetings held throughout the state. Health Plan Scheduler
Presbyterian-Albuquerque, NM
July 2012 to March 2013
Responsible for providing customer service for patients in regard to the triage of patients, scheduling appointments, referrals, messaging, and maintaining patient demographics. Respond to incoming calls routed through skill-based technology to meet quality standards and performance measurements. Is ready to take calls at the scheduled time, and spends the appropriate amount of time taking calls throughout their shift to resolve contacts on initial encounter. Conducts outbound calls as required and meets established quality-quantity guidelines supporting PHS-PHP-PMG initiatives and-or programs. Customer Care Representative
Verizon Wireless-Albuquerque, NM
July 2011 to July 2012
Assisted customers with various phone services, and billing issues. Responsibilities also included troubleshooting equipment problems and providing customers with promotional information, as well as upgrading customers to the newest equipment available to them. Customer Care Supervisor
Sitel-Albuquerque, NM
June 2010 to May 2011
Responsible for taking high priority escalated calls when a customer requested to speak with a Supervisor. Managed a team of 20+ agents. Provided daily coaching with agents to ensure that they were meeting the required metrics for the department. Managed my team’s attendance, corrective actions as well as approved time off as requested.
Customer Relations Specialist
T-Mobile Wireless-Albuquerque, NM
December 2008 to March 2010
Provide written correspondence stating T-Mobile’s position to the customers’ written correspondence. Independently gather relevant supporting data from appropriate points of contact within the company. Operate numerous types of office equipment. Investigate, research, and resolve customer issues in a timely fashion. Make decisions that will balance the customers’ needs as well as those of T-Mobile. Assisted customers with various phone, service, and billing issues. Responsibilities also included troubleshooting equipment problems and providing customers with promotional information.
Executive Customer Relations Specialist IV
T-Mobile Wireless-Albuquerque, NM
November 2005 to December 2008
Serve as administrative liaison between the legal department and company management. Provide written correspondence stating T-Mobile’s position to Governmental Consumer Agencies and attorneys. Independently gather relevant supporting data from appropriate points of contact within the company. Provide oversight and supervision to other administrative and customer relations staff, acting as mentor; train newly-hired personnel. Operate numerous types of office equipment. Investigate, research, and resolve customer issues in a timely fashion.
Make decisions that will balance the customers’ needs as well as those of T-Mobile.
Offline SIM/MSISDN Representative-Level II
T-Mobile Wireless-Albuquerque, NM
October 2002 to November 2005
Worked behind the scenes of T-Mobile. Worked within Remedy to process forms for SIM Unlock, MSISDN Maintenance and SIM Reuse. I was frequently asked to act as the Point of Contact in the absence of my Coach and Senior Representative. I also handled all projects that are given to the team. I was cross trained in HSE
(Handset Exchange), WEB Correspondence, Customer Relations, ABR (Advanced Billing Research) and RAC’s (Return Address Cards).
Customer Care Representative III (Information Support Line) VoiceStream/T-Mobile Wireless-Albuquerque, NM
March 2002 to October 2002
Responsible for assisting customer care representatives at a national level by directing the representative through job applications to locate call related information. Was also responsible for taking high priority escalated calls on customer and employee accounts. Customer Care Representative I
VoiceStream Wireless-Albuquerque, NM
August 2001 to March 2002
Assisted customers with various phone services, and billing issues. Responsibilities also included troubleshooting equipment problems and providing customers with promotional information.
Medical Secretary/Patient Service Representative/ER Tech Trainee Lovelace Health Systems-Albuquerque, NM
March 2000 to August 2001
Registered Emergency Room patients, as well as processed orders given by nurses and doctors, for the patients that were seen in the facility. Took co-payments from customers while they were registered. Requested medical records, and assisted in placing long-term patients in rooms throughout the Hospital. While being trained, I was learning sterilization techniques, as well as sent dirty instruments to the decontamination area. I am familiar with some instruments. Shift Manager
McDonalds-Albuquerque, NM
February 1994 to August 2001
Performed basic duties daily, which included balancing daily ledgers, making deposits, checking product availability, as well as maintained good customer service throughout my shift. Education
High school diploma
Rio Grande High School - Arenal, NM
August 1992 to May 1996
Skills
• Customer service
• Computer skills
• Microsoft Word
• Documentation Review
• Quality Audits
• OOP
• Medical office experience
• Insurance verification
• Medicare
• Medical terminology
• Communication skills
• Microsoft Office
• Sales
• Cash register
• Medical records
• Supervising experience
• Epic
• Shift management
• HIPAA
• Cold calling
• Hospital experience
• Leadership
• ICD-10
• Mentoring
• Team management
• Research
• Budgeting
• Office management
• Medical office management
• Cash handling
• Management
• Organizational skills
• Administrative experience
• QuickBooks
• Payroll
• Dental terminology
• Writing skills
• English
• Analysis skills
• Driving
• Recruiting
• Microsoft Outlook
• Time management
• Medical scheduling
• Patient care
• Google Suite
• Filing
• Appointment scheduling
• Clerical experience
• Working with people with developmental disabilities
• Working with people with disabilities
• Practice management
• Clinic
• Medical billing
• Spanish
• Healthcare management
• Accounts receivable
• Bilingual
• Organizational skills
• Medical office experience
• Patient observation
• Care Coordinator
• EMR Systems
Languages
• Spanish - Fluent
Certifications and Licenses
Driver's License
CPR Certification
August 2024 to August 2026
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