Looking for a job

Richard Guma

@richardguma

Message

I build compliant musculoskeletal care, utilization review, and fraud-risk programs for healthcare organizations.

United States

Message

What I'm looking for

I'm looking to lead or advise healthcare organizations on compliant clinical operations, utilization review, fraud-risk analysis, documentation integrity, and cost-containment programs.

At Optum Medical Care of NJ, I founded, scaled, and directed a Conservative Spinal Care service line, embedding evidence-based MSK care into clinical, operational, and regulatory workflows. I designed Epic documentation architecture, compliance guardrails, and audit-ready processes to reduce billing variance and support payer requirements.

Through Guma Healthcare and Consulting, I advise insurers and healthcare organizations on utilization review, medical necessity, SIU support, provider-behavior analysis, and cost containment. I bring 30+ years of clinical, compliance, and healthcare fraud-detection experience to help leaders identify documentation vulnerabilities, overutilization, and regulatory risk.

Experience

Work history, roles, and key accomplishments

Practicing Director of a Conservative Spinal Care Department

Optum Medical Care Of NJ

Jan 2017 - Jan 2026 (9 years)

Founded, scaled, and directed Optum NJ's Conservative service line within a large multi-specialty physician group, integrating evidence-based conservative MSK care into its clinical, operational, and regulatory infrastructure. Established standardized workflows and documentation guardrails to enforce compliance and minimize utilization variance.

Epic Healthcare Compliance Utilization Review Clinical Documentation Regulatory Compliance Billing Analysis Telehealth