1. Crystal Ann Gomez
8866 Wheeler Avenue
Fontana, CA 92335
(909)969-0604
mrscrystalgomez@gmail.com
Objective: A dedicated, inquisitive and success seeking professional seeking a Compliance Business Analyst position, offering a
challenging united environment for growth.
Employment:
Inland Empire Health Plan – Claims Internal Auditor 10/12 – Present: Responsible for recovery of overpayments compliant
with contractual and regulatory requirements. Trending of errors such as: duplicates, coordination of benefits, share of cost,
and claims being paid to an incorrect provider. Duties also include responding to CRM tasks, compliance issues,
communicating with Providers, Attorneys and other internal departments, pursuing of Third Party Liability for Medicare and
Healthy Families and CCS paid claims and researching and applying refund checks to claims. Previous functions included
check run report which was presented to the CFO weekly, a weekly audit report that was given to the claims department and
monthly retraction report to recover monies contractually owed to IEHP. Current projects include possible identity theft fraud
case (with Compliance), occasionally leading an RIE huddle for (Finance) monthly reconciliation, and currently constructing an
RIE for refund determination process. Expertise in Diamond, CRM, Excel, Word, navigating fee schedules, contracts, CMS and
Medi-Cal websites and good grasp on Access databases.
ProMed Healthcare Administrators – Claims Auditor 04/07 – 10/12: Responsibilities include daily auditing of claims ranging
from Medicare, commercial, Healthy Families & Medi-Cal lines of business and full risk for senior line of business. Maintaining
error and production logs for staff and answering claims questions. Monitors and reports errors and trends to Supervisor and
attended check run meetings to explain payment. In the absence of Auditor, I was responsible for 2 IPA’s for extended period of
time of 10+ staff; presently I audit 5 examiners while following HIPAA protocol. Processing UB92, HCFA 1500, EDI and
scanned claims including, reviewing and inputting data into processing system using standard policies, procedures and
guidelines while meeting production standards (75 UB-92, 125 HCFA 1500, 550 EDI and scanned claims) and accuracy
standards above 98%. Excellent knowledge of EZ-CAP, Virtual Auth Tech, Ingenix Encoder Pro & PM Audit.
Inland Empire Health Plan – Claims Examiner II 12/06 – 04/07: Responsibilities include examining 250 claims ranging from
Medi-Cal, health families to commercial while maintaining a 98.5% accuracy, pend reports, and working on special projects as
needed such as cap deducting IPA’s and ambulance claims. Ability to read and apply Medi-Cal fee schedule and excellent
knowledge of Diamond database.
Primary Provider Management Company – Claims Analyst 08/06 – 12/06: Responsibilities included analyzing complex Medi-
Cal claims. Efficient knowledge of Medi-Cal guidelines, rules and regulations. Efficient knowledge of HMS system and Code
Manager Database. Knowledge of OB and Oncology claims.
ProMed Healthcare Administrators – Claims Examiner I 04/06 – 08/06: Responsibilities included processing routine claims by
reviewing, coding, and inputting data into the information system using standard policies, and editing of claims ranging from
Medi-Cal, Healthy Families, Commercial and Senior lines of business. Efficient in EZ-CAP, Redbook for Windows and Virtual
Auth Tech programs.
Riverside Physicians Network – Claims Processor 03/03 – 06/05: Responsibilities included scanning claims with Teleform
Program. Experienced with Viual FoxPro program. Worked with eligibility on health plan websites as well as fixed errors on
claims. Processed senior and commercial claims. Efficient in Communicap program. Knowledge of CPT and ICD-9 and 10
codes as well as some medical terminology.
Education:
Chaffey College – Currently attending for Associate degree in Small Business Entrepreneur
San Joaquin Valley College – Obtained Associate of Science degree in Pharmacy Technology September 2003
Ramona High School – Obtained High School diploma in General Education June 2000