Raquel Garcia
Groveland,FL
Summary
Over 35 years of comprehensive experience in the healthcare industry, specializing in administrative support and revenue cycle management
Overview
17
17
years of professional experience
1
1
Certification
Work History
UM Administration Coordinator 2
Humana
05.2021 - Current
- Provide administrative support to the Humana Transplant Utilization Management and CIT Medicaid department
- Handle the processing of both inpatient and outpatient authorizations for members via fax and phone
- Analyze, research, and confirm provider participation in member's selected insurance policy
- Accurately assign authorizations to the correct queue to uphold compliance standards
- Conduct daily outreach to providers by phone and/or email regarding case statuses for accurate processing of claims
- Address inquiries, responding promptly and uploading necessary clinical documentation to support cases
- Efficiently build and update UM & CM cases in CGX
- Review medical records related to admissions or current stays, associating them with the correct cases in preparation for medical necessity reviews
- Request clinical documentation from providers in accordance with Medicare guidelines for clinical review processes
- Review member contracts for transplant benefits and complete benefit assessments for commercial members in CGX
- Answer inbound calls from members and providers, directing them to the appropriate party and documenting all interactions
- Assist the department in achieving its organizational goals and maintaining compliance
Administrative assistant/receptionist
Conviva-Center Well Center
08.2020 - 05.2021
- Served as the first point of contact for patients and visitors
- Input patient’s demographic into ECW/EMR system
- Maintained and uploaded patient’s records ensuring accuracy and confidentiality
- Faxing, scanning and uploading documents in ECW/EMR system
- Assisted the clinical department in highlighting Start/HEDIS opportunities
- Partner with the clinical staff and practice administrator to identify trends observed to potential strategies to support the practice
- Performed daily reports and other office duties assigned by the administrator
- Provided training and helped new employees onboard
Assistant Office Manager
Clermont Health and Rehab Center Nursing Home
11.2018 - 03.2020
- Submitted claims regarding payment resolution to Medicare, Medicaid, Commercial insurance, and patients
- Collaborated closely with different departments, vendors, residents and residents’ families to deliver operational efficiency to the facility
- Assisted case managers with coordination of care for complex healthcare and placements needs
- Acted as liaison between the business office, social services and nursing to resolve all grievances
- Maintained accurate upkeep of daily census records within the EMR system
- Conducted thorough analyses and reviews of claims, working closely with external collaborators to remediate denials and overpayments
- Oversaw provider contracts to maintain service level agreements and compliance
- Executed appeals, reconsiderations, and necessary write-offs to correct billing discrepancies
- Verified all payer requirements, including pre-certifications and levels of care
- Managed Medicaid applications and re-certifications to ensure continuity of care
- Processed Accounts Payable, managing all vendors
- Oversaw Accounts Receivables, including the generation of all revenue reports
- Assisted in the processing of month-end closings
- Trained new employees
Business Office Manager
Bedrock Rehabilitation and Nursing Home at Lake Eustis
08.2015 - 04.2017
- Managed business office operations, including planning and execution
- Conducted employee performance reviews, check-ins, training, and other personnel management tasks
- Analyzed and remediate patient grievances
- Maintained accurate daily census records within the EMR system
- Addressed outstanding claims by conducting detailed analyses, presenting findings, and collaborating with relevant payers
- Managed monthly billing procedures for Medicare, Medicaid, and private insurance
- Oversaw billing, collections, denials, and overpayments ensuring compliance with cash handling procedures
- Managed provider contracts, negotiating terms that consistently secured favorable rates
- Supervised pending Medicaid applications, coordinating with DCF, Elder Affairs, and other parties to secure long-term approvals
- Led month-end closings
- Managed patient Trust accounts with strict adherence to regulatory standards
- Govern all Payroll and Accounts Payable activities
Reimbursement Lead & Financial analyst
The Howard Phillip Center for children and family
02.2009 - 02.2013
- Managed the end-to-end revenue cycle process
- Monitored accounts receivable aging reports and followed up on outstanding claims
- Prepared report on revenue cycle performance metrics for management review
- Reviewed prepared and analyzed claims for processing, certifying accurate coding and charge capture
- Supervised all claims, ensuring timely settlements
- Addressed payer requests for additional information regarding claims processing
- Assessed provider contracts guaranteeing reimbursement terms are met
- Worked with internal departments to prepare HEDIS’s reports
- Reviewed HEDI’s data reports to identify trends and gaps to provide insights
- Conducted daily report examinations, addressing all charge discrepancies
- Coordinated with providers to obtain necessary claim processing information
- Evaluated Explanation of Benefits co-pays, co-insurance, contractual adjustments, and details to facilitate training
- Trained new employees and created training materials
Education
Associates of Arts -
Valencia College
01.1988
Skills
- Software: CGX, ECW, Point Click Care, Microsoft Access, Excel, Word, Visio, RX Connect, HOWIE Certificate Search, Mentor, EMR, Availity
- Certificates: Humana SQL Certification (Pending)
- Soft Skills: Conflict Resolution, Customer Service, Root Cause Analysis, Critical thinking
- Languages: English: fluent, Spanish: fluent
- Other: Translations, Agile workflows
- Financial: Revenue Cycle Management, Provider Relations, Claims Research & Appeals, Credentialing, Business Process Improvements
Certification
CNA Certification 2024
Timeline
UM Administration Coordinator 2
Humana
05.2021 - Current
Administrative assistant/receptionist
Conviva-Center Well Center
08.2020 - 05.2021
Assistant Office Manager
Clermont Health and Rehab Center Nursing Home
11.2018 - 03.2020
Business Office Manager
Bedrock Rehabilitation and Nursing Home at Lake Eustis
08.2015 - 04.2017
Reimbursement Lead & Financial analyst
The Howard Phillip Center for children and family
02.2009 - 02.2013
Associates of Arts -
Valencia College
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