Racquel Carmona
Cerritos,CA
Summary
Over 30 years of experience in Medicare, Medicaid, Commercial and diverse managed care operations including customer relations, claims operations. Working with highly confidential information including claims, recovery, coordination of benefits, claims auditing, claims testing, adjustments, appeals, contracts, identifying, tracking and check reconciliation, data mining, reports, provider configuration, set-up and maintenance of managed records, unclaimed property, audit and recovery, program integrity, forager, and training. Extensive knowledge on Managed Care Contract Administration, TPA, Medical Terminology, HMO, PPO, POS, Managed Care, Behavioral Health, CPT codes, ICD9 & ICD10 codes, REV codes, DRG codes, HCPCS, UB04, HCFA1500, Per Diem, COB, Gov. State Laws for Medicare and Medicaid, Customer Relations. Strong organizational, communication and problem-solving skill, adaptable and dependable candidate, successful in managing multiple priorities with a positive attitude.
Overview
24
24
years of professional experience
1
1
Certification
Work History
Acting Operations Expert
Carelon Health
07.2025 - Current
- Facilitate the training and onboarding of new hires to integrate them effectively into the team.
- Provide guidance and support to associates as needed.
- Monitor and support associate productivity to meet operational goals.
- Conduct regular coaching sessions and one-on-one meetings with associates for performance improvement.
- Maintain and update payback trackers to ensure accurate accounting.
- List weekly approach document issues for the Lead to meet with the Forager for corrections.
- Address and rectify hard error claims for smooth processing.
- Conduct and support audits to ensure compliance and quality standards are met.
- Manage and address aging claims from assigned vendors.
- Attend to high-priority inventory to assist the team in meeting goals.
- Foster effective communication and collaboration with other departments.
- Handle special projects and assignments as directed by manager.
Financial Operations Recovery Specialist II
Carelon Health
04.2016 - 07.2025
- Evaluated and processed overpayment requests in FACETS Claims Processing Systems, knowledge of multiple CMS pricers (SNF/HHA/Psych pricers), executed and monitored related concept rebuttals. Provided rebuttal review determination outcome as appropriate for concept related recoveries.
- Expertise in the identification, investigation of FACET’s claims processing system and Webstrat pricing with the ability to summarize and present concerns to Management and Executive Leadership to determine appropriate actions.
- Collaborated with Data Analytics in the development of multiple recovery reports requiring specific claims data elements to determining the creation and validation CMS and billing error recovery concept reports for inpatient/outpatient for both professional and facility claims.
- Contract review, plan benefits, copays, coinsurance for dual coverages.
- Evaluated and processed voluntary refund check intake request in FACETs with validation, monitoring and tracking for accuracy.
- Coordinated and worked with Elevance Forager team in determination of high impact billing and payment errors for concept development. Currently on track with the developed Forager recovery concepts for recoveries with knowledge of Medicaid, Medicare, and commercial billing guidelines.
Claims Adjuster
St. Joseph Health Systems
04.2015 - 04.2016
- Research, validation, process and adjustment of claims for underpayments to the providers/vendors.
- Account resolution interpretation of insurance contracts, fee schedules and/or Federal or State guidelines.
- Special Project assignments from Management (DRG, REV, HCPCS, Rate Schedules, etc).
Cost Containment Lead
SCAN Health Plan
09.2001 - 03.2015
- Trained new associates and provided on-going training to Financial Operations Recovery Specialists
- Distributed work to staff and supports management daily, including maintenance of inventory reports.
- Assisted in collecting samples each month from each Recovery Specialists to audit for Quality.
- Audit paid claims for overpayments, using various techniques, including system-based queries, specialized reporting, or other research.
- Established rapport with staff and management from various departments to ensure high quality customer satisfaction.
- Collaborated with external vendors and internal data mining to validate overpayments, validate vendor invoice and provide feedback to modify queries when needed.
- Worked closely with management to identify and avoid errors on contractual issues, if applicable. Handle complex cases for research and resolution. Assists in special projects to find and prevent overpayments or to identify process improvements. Completes special projects with minimum supervision.
- Performed collection activities to ensure the recovery of overpayments and maintenance of unprocessed cash and accounts receivables processes and all other cash applications.
- Researched voluntary refunds and balancing all accounts for accuracy
- Reduced Backlog on Inventory
Education
Associate Degree - Vocational Nursing
Long Beach City College
Long Beach, CASkills
- Active listening
- Adaptability and flexibility
- Organizational skills
- Reliability
- Problem-solving abilities
Certification
- Microsoft Office (Excel, Access, Word, PowerPoint) Long Beach, CA
- Phlebotomy Kaiser Permanente Hospital Harbor City, CA
- Child Development Long Beach, CA
Timeline
Acting Operations Expert
Carelon Health
07.2025 - Current
Financial Operations Recovery Specialist II
Carelon Health
04.2016 - 07.2025
Claims Adjuster
St. Joseph Health Systems
04.2015 - 04.2016
Cost Containment Lead
SCAN Health Plan
09.2001 - 03.2015
Associate Degree - Vocational Nursing
Long Beach City College
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