Tyla Gonzales
Oxnard,CA
Summary
Sr. Claims Analyst Lead directing 6–8 analysts weekly across DSNP and Medi-Cal claims adjudication, large-dollar claim review of 31+ claims per month, and escalated issue resolution across pricing, benefit interpretation, and system configuration. Leads analyst training, workflow redesign, and QA checkpoints to reduce errors and improve auto-adjudication performance by 11–20%. Partners with provider contracting, IT, and regulatory teams to align contract builds, claims logic, and CMS/DHCS compliance.
Overview
1
1
Certification
39
39
years of professional experience
Work History
Sr. Claims Analyst Lead
Gold Coast Health Plan
Camarillo, CA
01.2016 - Current
- Lead a team of seven analysts overseeing high-volume DSNP and Medi-Cal claims adjudication.
- Conducted benefit analysis and adjudicated large-dollar claims exceeding $50K to ensure accurate processing.
- Reduce claims error rates through targeted training, workflow redesign, and QA checkpoints.
- Perform complex claims research and resolve escalated issues involving provider disputes, pricing errors, benefit interpretation, and system configuration.
- Partnered with IT to enhance auto-adjudication logic, resulting in increased autopay rates.
- Conduct root-cause analysis on recurring denials to improve provider satisfaction and reduce rework.
- Collaborated with provider contracting to validate reimbursement structures and identify contract leakage, ensuring alignment with negotiated terms.
- Serve as SME for CMS and DHCS regulatory updates, ensuring claims compliance and audit readiness.
- Manage DHCS regulatory rate updates for long-term care, medical supplies, and specialized benefit categories.
- Provide SME guidance on CARC/RARC usage and EDI 837 transaction handling.
- Act as claims liaison for contracted hospitals and health centers across Ventura and Los Angeles Counties.
- Oversee review and approval of claims variance reports following system updates.
Participant Service Supervisor
Screen Actors Guild Producers Pension & Health Plan
Burbank, CA
01.2013 - 01.2016
- Assisted members, providers, and participants with inquiries regarding benefits, eligibility, and membership to ensure clarity and satisfaction.
- Performed escalated claims adjustments and provided training on claims and customer service.
- Monitored Service Factor Percentage and supported overflow calls to meet the 60-second response goal.
- Tracked Service Factor Percentage and managed overflow calls to consistently achieve 60-second response goal.
- Compiled daily/weekly/monthly VPI performance reports to provide insights for operational improvements.
- Prepared daily/weekly/monthly VPI performance reports.
- Conducted UAT testing for system implementations and reported issues.
Lead Claims Service Representative / Claims Liaison
Screen Actors Guild Producers Pension & Health Plan
Burbank, CA
01.2001 - 01.2013
- Served as liaison with Anthem Blue Cross to resolve claims, pricing, and contract issues.
- Analyzed vendor reports from Anthem Blue Cross to ensure accurate benefit payments and eligibility, identifying issues with COB, SF updates, and invalid DF/RF codes.
- Completed escalated claim adjustments and provided backup support for Appeals.
- Supervised claims examiners while developing comprehensive training materials to enhance team knowledge and performance.
- Acted as liaison with Anthem Blue Cross to effectively resolve claims, pricing discrepancies, and contract-related issues.
- Updated COB details, set up claims for medical review, and processed accident/subrogation documentation.
- Assisted with QA scorecard reviews and training recommendations.
COB Auditor
Primax Recoveries
CA
01.1999 - 01.2001
- Reviewed claim files across multiple carriers to ensure accurate COB determination.
- Contacted providers to verify primary insurance status and facilitate necessary billing updates.
- Prepared files for collection activity while managing 50–80 cases daily to maintain workflow.
- Prepared files for collection activity and managed 50–80 cases per day.
Claims Benefit Specialist
Nylcare dba Aetna US Healthcare
Camarillo, CA
01.1997 - 01.1999
- Reviewed medical and dental claims to ensure accuracy and proper benefit application.
- Delivered customer service support to self-funded employer groups, addressing inquiries and resolving issues.
- Oversaw management of claim appeals, overpayments, and adjustments to facilitate timely resolutions.
Claims Supervisor
Ventura Insurance Administrators
Ventura, CA
01.1988 - 01.1997
- Oversaw Claims Examiners and data entry staff to ensure accurate claim processing.
- Supervised Claims Examiners and Data Entry staff.
- Trained new staff and collaborated with Utilization Review and Provider Relations.
- Trained new staff while collaborating with Utilization Review and Provider Relations to streamline claim resolution.
- Priced Workers’ Compensation claims and managed Foundation for Medical Care network repricing to maintain compliance and accuracy.
Education
Beginning Excel
Ventura Technology Center
Ventura01-2004
Business English
Oxnard College
Oxnard01-1999
GED - undefined
Oxnard Adult Education
Oxnard01-1997
Skills
- Claims processing
- Claims auditing
- Benefit design
- Medicare
- Medi-Cal
- Provider contract analysis
- Claims adjudication
- Denials management
- Reimbursement analysis
- Regulatory compliance
- Policy development
Certification
- Educational Series Training Program – 2009
- Cultural Alignment Workshop - 2025
Timeline
Sr. Claims Analyst Lead
Gold Coast Health Plan
01.2016 - Current
Participant Service Supervisor
Screen Actors Guild Producers Pension & Health Plan
01.2013 - 01.2016
Lead Claims Service Representative / Claims Liaison
Screen Actors Guild Producers Pension & Health Plan
01.2001 - 01.2013
COB Auditor
Primax Recoveries
01.1999 - 01.2001
Claims Benefit Specialist
Nylcare dba Aetna US Healthcare
01.1997 - 01.1999
Claims Supervisor
Ventura Insurance Administrators
01.1988 - 01.1997
GED - undefined
Oxnard Adult Education
Business English
Oxnard College
Beginning Excel
Ventura Technology Center