Gabriel Dumaguin

Results-driven Healthcare Revenue Cycle Management (RCM) professional with 3+ years of specialized experience in medical billing, technical denial management, insurance claim resolution, and No Surprises Act (NSA) arbitration. Proven expertise in optimizing reimbursement workflows, reducing AR aging backlogs, and resolving complex technical denials across EPIC and Cerner EHR systems. Adept at navigating payer guidelines, ensuring 100% HIPAA compliance, and facilitating seamless administrative and medical support for U.S. healthcare providers.

Arbitration Specialist – No Surprises Act (NSA) at Cloudstaff (2025-12 – Present)

• Spearheaded the recovery of high-value out-of-network claims by directly negotiating with commercial payers and navigating specialized provider portals.
• Managed end-to-end Independent Dispute Resolution (IDR) and arbitration cases under the No Surprises Act (NSA), maintaining 100% compliance with federal CMS standards.
• Audited reimbursement shortfalls and fee schedule variances in Payment Integrity Compass (PIC) to pinpoint underpayment trends and maximize cash recovery.
• Prepared and submitted formal arbitration filings to the CMS IDR portal within strict statutory deadlines, accelerating dispute resolution timelines.
• Reconciled aged AR accounts and monitored dispute statuses to lower average Days in AR and optimize cash flow turnaround for U.S. healthcare providers.

AR Technical Denial at Conifer Health Solution (2024-09 – 2025-12)

• Executed end-to-end technical denial analysis and accounts receivable follow-up while strictly maintaining 100% HIPAA and patient data privacy compliance.
• Drafted and submitted detailed technical appeals and medical necessity reconsiderations, successfully overturning claim denials and securing full reimbursement.
• Posted patient and insurance payments accurately, evaluating Explanation of Benefits (EOB) and Electronic Remittance Advice (ERA) to process timely adjustments and refunds.
• Identified and rectified CPT, ICD-10, and demographic error patterns to eliminate front-end clearinghouse rejections and improve first-pass claim yield.

AR Denial Analyst at MedMetrix International (2024-03 – 2024-09)

• Investigated and resolved complex aged claims through proactive outreach to U.S. insurance carriers via phone, payer portals, and written correspondence.
• Validated primary and secondary patient eligibility, benefits coverage, and COB details using clearinghouse tools to prevent pre-billing claim rejections.
• Analyzed recurring denial trends and collaborated with billing leadership to update clinical documentation and workflow processes, reducing rework.

Member Advocate at ResultsCX (2022-11 – 2024-02)

• Delivered high-volume administrative customer service to healthcare plan members, facilitating appointment scheduling, enrollment, and plan reinstatement.
• Educated policyholders on complex healthcare benefit structures, including deductibles, co-pays, coinsurance, and out-of-pocket maximums.
• Initiated prior authorization requests, claim appeals, and member grievances in strict alignment with plan guidelines and regulatory standards.

BS in Information Technology (2nd Year) – Our Lady of Fatima University-Antipolo