Catherine Gomez
Pembroke Pines
Summary
- Dynamic professional with extensive experience managing the complete insurance claims process, emphasizing exceptional customer service and strict adherence to company policies.
- Comprehensive knowledge of medical insurance and terminology enables effective communication that fosters understanding and supports team development.
- Proven accuracy and efficiency in data entry, backed by advanced technical skills on contemporary claims platforms.
- Highly organized and adept at multitasking, consistently meeting priorities and deadlines in fast-paced environments while serving as a reliable team collaborator with a positive, detail-oriented approach to achieving performance goals.
Overview
13
13
years of professional experience
Work History
CL Claims Specialist Intermediate
Progressive Casualty Insurance
Remote
12.2024 - Current
- Assessed and analyzed coverage for moderate complexity injury claims involving attorney representation.
- Analyzed and identified questionable claim attributes, leading to the initiation of in-depth accident investigations.
- Developed rapport with legal professionals to streamline settlement discussions and expedite resolution processes.
- Evaluated legal documentation, demands, complaints, and suits to determine litigation exposure.
- Conducted comprehensive analysis of medical records to assess injury costs and determine settlement ranges.
- Facilitated self-training and proficiently navigated various medical platforms to streamline injury offer execution and authorization acquisition.
- Coordinated with team members and other departments to ensure efficient management of workloads and fulfillment of organizational objectives.
CL Claims Generalist Intermediate
Progressive Casualty Insurance
Remote
03.2024 - 12.2024
- Assessed and interpreted commercial policies to guide strategic decisions in claim handling processes.
- Conducted thorough investigations and adjustments of claims to ensure compliance with state-specific regulations.
- Analyzed business metrics and customer needs to negotiate tailored injury settlements effectively.
- Drafted coverage letters for injury releases and denials, ensuring clarity and compliance with regulations.
- Evaluated suspicious activities to uncover potential fraud and organized cases for subsequent investigative action.
- Oversaw claims inventory management, diary tracking, and communication processes to enhance workflow efficiency.
- Mentored junior staff on best practices in claims management and customer service excellence.
Claims Generalist Intermediate
Progressive Casualty Insurance
Miramar, FL
01.2023 - 03.2024
- Evaluated and resolved unrepresented bodily injury claims within established timeframes.
- Reviewed endorsements and policy specifics to uphold accuracy in claims management.
- Reviewed and documented property damage assessments, overseeing repair processes to maintain compliance and accuracy.
- Analyzed and identified subrogation opportunities and fraudulent claims for further investigation.
- Oversaw organization of claim inventory and ensured timely processing of payments with proper authorization.
Medical File Owner
Progressive Casualty Insurance
Miramar, FL
09.2022 - 01.2023
- Evaluated claims to guarantee adherence to compliance standards and facilitate prompt resolution.
- Conducted thorough compilation and arrangement of medical records and treatment histories to support claims prequalification accuracy.
- Facilitated approval of settlements exceeding direct report limits while effectively resolving complex escalated inquiries.
- Oversaw total loss claims process, ensuring precise documentation and timely payment execution.
- Conducted thorough reviews of questionable claims, ensuring all supporting evidence was accurately documented for investigation.
- Managed timely repair processes by contracted providers to ensure operational efficiency.
Claims Generalist Trainee
Progressive Casualty Insurance
Miramar, FL
05.2022 - 08.2022
- Evaluated and resolved auto claims by analyzing initial reports and determining coverage and liability, facilitating efficient claims processing.
- Conducted detailed interviews and meticulously recorded statements from both insureds and claimants.
- Collaborated with appraisers to oversee estimates, repairs, and total loss processes.
- Delivered exceptional customer service and upheld professional integrity while achieving learning objectives.
- Analyzed claim data to identify trends and recommend process improvements for efficiency.
- Managed case loads effectively, prioritizing tasks to meet service level agreements consistently.
- Maintained a positive work environment by fostering open communication, collaboration, and continuous learning among team members.
Inbound Sales (Bilingual) Representative
Comcast Business
Miramar, FL
10.2019 - 05.2022
- Achieved and exceeded monthly sales goals to enhance customer satisfaction and loyalty.
- Analyzed client needs and negotiated customized plans and packages to enhance business outcomes utilizing consultative sales methods.
- Optimized transaction workflows by effectively utilizing multiple systems and applications.
- Facilitated team collaboration to promote a supportive and positive work environment.
- Facilitated account management processes, enhancing client satisfaction through tailored support.
- Managed bilingual customer interactions, ensuring clear communication and resolving inquiries efficiently.
Analyst Medical Billing Specialist
H2 Hospitalist Group
Miami, FL
12.2017 - 06.2019
- Analyzed and corrected hospital face sheets, discharge summaries, and medical notes, focusing on detail and accuracy.
- Executed authorization verification and directed Medicare/Medicaid billing activities using Availity platform.
- Achieved flawless daily claim submissions, contributing to operational efficiency. Resolved denials and appeals promptly, enhancing overall claims processing effectiveness.
- Reviewed EOBs and coordinated with billing managers to ensure timely resolution of reimbursement issues.
- Analyzed patient data to identify trends and improve care protocols.
- Developed comprehensive reports to support decision-making processes for hospital management.
- Conducted regular audits of data sources, ensuring compliance with regulatory standards and internal policies.
- Improved internal knowledge sharing by developing comprehensive documentation outlining standard operating procedures for various tasks.
Fourth Grade Teacher
Growing Treasure Private School
Hialeah, FL
06.2016 - 07.2017
- Created and instituted comprehensive instructional methods and curriculum frameworks to foster an enriched learning environment for students.
- Designed and implemented lesson plans and instructional tools to enhance student learning experiences.
- Managed progress report documentation and led parent-teacher meetings to foster communication regarding student growth.
- Implemented a classroom management system that promoted positive behavior and student accountability.
- Collaborated with colleagues to integrate interdisciplinary approaches into curriculum design and instructional strategies.
- Assessed student progress through various evaluation methods, adapting instruction to meet diverse learning needs.
- Coordinated extracurricular activities that enriched the educational experience and promoted community involvement among students.
- Improved student comprehension by incorporating real-life examples and hands-on activities into lessons.
- Prepared and administered grade-specific tests and examinations regulated by school district to monitor students' growth and to report progress to parents.
- Administered various reading tests and determined student reading levels based on assessment findings.
Customer Care Associate
Magellan Complete Care
Miami, FL
06.2013 - 03.2016
- Addressed member inquiries regarding eligibility, benefits, claim status, and authorizations while ensuring confidentiality.
- Responded to crisis calls and orchestrated communication with clinicians to guarantee resolution of issues.
- Ensured accurate entry of patient data and prepared comprehensive documentation to support care processes.
- Engaged in mentoring and training of new staff while actively participating in performance enhancement initiatives.
- Resolved customer inquiries and complaints through effective communication and problem-solving techniques.
- Managed case documentation using CRM software to ensure accurate record-keeping and follow-up actions.
- Balanced multiple priorities simultaneously, ensuring timely completion of tasks without compromising quality standards.
Education
Associate of Science in Education - Elementary Education
University of Phoenix
Miramar, FLEarly Childhood Education & Neglect (45 Hours) - Child Development
FL Dept of Children & Families
Miami, FLMedical Coding & Billing (Licensed) - Health Administration
Florida Career College
Miami, FLSkills
- Skilled in QuickBooks and Workforce management
- Proficient in data analysis tools
- Proficient in English and Spanish communication
- Awareness of healthcare privacy laws
- Experienced in negotiation strategies
- Insurance claims review
- Cross-functional collaboration
- Claims administration
- Proficient in delivering clear messages both orally and in writing
Accomplishments
- CGA to CGI Program Mentor
- Directory Advisory Board Member
- Stress Free PTO Program Member
- We Team Member
Languages
English
Native or Bilingual
Spanish
Native or Bilingual
Timeline
CL Claims Specialist Intermediate
Progressive Casualty Insurance
12.2024 - Current
CL Claims Generalist Intermediate
Progressive Casualty Insurance
03.2024 - 12.2024
Claims Generalist Intermediate
Progressive Casualty Insurance
01.2023 - 03.2024
Medical File Owner
Progressive Casualty Insurance
09.2022 - 01.2023
Claims Generalist Trainee
Progressive Casualty Insurance
05.2022 - 08.2022
Inbound Sales (Bilingual) Representative
Comcast Business
10.2019 - 05.2022
Analyst Medical Billing Specialist
H2 Hospitalist Group
12.2017 - 06.2019
Fourth Grade Teacher
Growing Treasure Private School
06.2016 - 07.2017
Customer Care Associate
Magellan Complete Care
06.2013 - 03.2016
Associate of Science in Education - Elementary Education
University of Phoenix
Early Childhood Education & Neglect (45 Hours) - Child Development
FL Dept of Children & Families
Medical Coding & Billing (Licensed) - Health Administration
Florida Career College