Summary
Overview
Work History
Education
Skills
References
Timeline
Generic

Troy Gonzales

Conroe,TX

Summary

Skilled Medical Administrator ready to pursue new professional challenges in the healthcare industry. Successful at overseeing diverse healthcare administrative projects from pre-service authorization, peer to peer, claim submission. clearinghouse rejections, claims appeals, claims projects, and claims project resolution

Overview

13
13
years of professional experience

Work History

Escalation Account Supervisor

United Healthcare Group
Houston, TX
02.2020 - 01.2024
  • Assisted in developing and refining standard operating procedures for floor agents in the Provider Service Dept.
  • Served as a subject matter expert in an elevated capacity with specialized complex Medicare/Medicaid issues needing to be escalated for project initiation
  • Created and maintained multiple claims/authorization projects and triaged according to business need and medical necessity

Provider Relations Advocate

United Healthcare Group
Houston, TX
02.2018 - 02.2020
  • Instructed providers on procedures and policy limitations for Medicare and Medicaid plans.
  • Responded promptly to inquiries from providers regarding authorization requests, payment issues, benefit coverage determinations.
  • Eliminated contractual risks by instructing providers and coordinating educational material distribution.

Prior Authorization Specialist

United Healthcare Group
Houston, TX
02.2011 - 02.2018
  • Reviewed prior authorization requests for completeness and accuracy.
  • Researched medical policies to ensure appropriate coverage of services.
  • Processed appeals for denials in accordance with established procedures.
  • Notified ordering providers of denied authorizations.

Education

Associate of Science - Biology

Lonestar Community College
The Woodlands, TX

Skills

  • Eligibility Verification
  • All aspects of Prior Authorization and appeals/State Fair Hearing processes
  • Subject matter expert involving Medicare/Medicaid policies including Reimbursement Policies, Contractual Agreements, Claims Timely Filing, HIPAA Regulation and PHI management
  • Expert knowledge of State and Federal websites and Provider Portal navigation

References

References available upon request.

Timeline

Escalation Account Supervisor

United Healthcare Group
02.2020 - 01.2024

Provider Relations Advocate

United Healthcare Group
02.2018 - 02.2020

Prior Authorization Specialist

United Healthcare Group
02.2011 - 02.2018

Associate of Science - Biology

Lonestar Community College

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