Toni Abeyta
Long Beach,CA
Summary
Experienced health plan leader with 20+ years in Medicare and Medicaid claims operations and a Certified Medical Reimbursement Specialist (CMRS). Proven ability to direct complex workflows across claims production, audit, recovery, provider escalations, and mailroom/OCR operations. Recognized for stabilizing high-visibility operational issues, leading cross-functional corrective actions, and improving performance through data-driven analysis and process design. Skilled in regulatory interpretation, contract analysis, escalated claim resolution, and compliance oversight. Strong communicator and team leader with a track record of mentoring staff, managing vendors, and implementing workflow and technology improvements—including early RPA/AI audit enhancement initiatives. Known for operational steadiness, collaborative leadership, and delivering high accuracy and quality across claims functions.
Overview
18
18
years of professional experience
1
1
Certification
Work History
Manager Audit & Recovery/Provider Escalations
SCAN Health Plan
Long Beach, CA
01.2017 - Current
- Direct and oversee 23 employees to ensure team’s responsibilities for audit, overpayment recovery and provider escalated issues are delivered accurately, timely and in accordance with contractual and regulatory requirements. Interact collaboratively with internal department leadership and interdepartmental business leads to improve operational business workflows and processes.
- Lead a 23-member team responsible for audit, overpayment recovery, escalations, and compliance-aligned outcomes across MA lines of business.
- Oversee claims mailroom operations, including OCR vendor (SDS) management, new software implementation, staff training, and weekly inventory control of 1,900+ claims.
- Provide operational oversight of claims production vendor teams, including weekly SLA reviews, audit alignment, inventory monitoring, and issue resolution.
- Developed and implemented an audit peer-review program to identify training needs and deliver more consistent audit results.
- Designed and operationalized the end-to-end claims process for the VBID Hospice program, achieving a 99% internal accuracy rate.
- Serve as SME for AI/RPA assessment and process-modernization initiatives for audit and claims operations.
- Prepare and deliver weekly operational reports to leadership focused on trends, inventory status, quality metrics, and compliance risks.
- Partner cross-functionally with Network Management, Legal, SIU, Finance, Compliance, and Provider Relations to resolve escalated and complex provider issues.
- Interpret contract language, benefits, delegated arrangements, and regulatory requirements to determine appropriate liability and resolution.
- Direct staff development, cross-training, and resource allocation in response to inventory fluctuations, compliance needs, and organizational priorities.
- Interim Support of Claims Director Function (May 2021 – Jan 2022; ongoing support)
- Provided temporary operational support and coverage for the Claims Director role following leadership retirement in May 2021 until the new Director’s arrival in January 2022.
- Continue to support the temporary Claims Director with claims production oversight, escalations, vendor issue resolution, and inventory governance.
- Work directly with SCAN’s claims production vendor to assess workloads, ensure timely/accurate adjudication, resolve complex claims issues, and support overall department stability.
Supervisor Claims Recovery & Provider Escalations
SCAN Health Plan
Long Beach, CA
01.2016 - 01.2017
- Responsible for oversight of the Recovery and Provider Escalations team. Owned and established interdepartmental relationships with Provider Network Representatives, Case Management and Legal to resolve provider claims issues.
- Managed the Recovery and Provider Escalations team, partnering closely with Network Management, Case Management, and Legal to resolve provider concerns.
- Coordinated reconciliation of provider negative balance issues.
- Represented Claims in SIU-led initiatives addressing recovery and audit outcomes.
- Oversaw special projects to maximize recovery results and reduce financial exposure.
Claims Recovery Resolution Analyst
SCAN Health Plan
Long Beach, CA
01.2015 - 01.2016
- Managed the working relationship within the department with Provider Network Advocate team to address attorney conference calls, prepare project summaries for presentation in joint operation meetings with hospital staff, physician groups and other ancillary providers. Develop and lead audit and recovery processes to reduce loss in revenue due to process errors.
- Served as SME for providers, assisting with remittance reconciliation and claims dispute resolution.
- Analyzed examiner errors and developed training materials to improve departmental quality.
- Reviewed claim overpayments and issued recovery letters; contributed to special audit and recovery initiatives.
Provider Services Analyst, Senior
SCAN Health Plan
Long Beach, CA
01.2010 - 01.2015
- Maintained 100% compliance on Medicare provider appeals and disputes.
- Collaborated closely with Network Management and Legal on high-visibility provider matters.
Senior Medical Claims Examiner
SCAN Health Plan
Long Beach, CA
01.2008 - 01.2010
- Supported Claims Department claims processing and resolution delivery to provider inquiries. Positively contributed to the department’s performance and routinely identified opportunities to enhance existing SOPs.
- Processed 100+ claims daily with 98% accuracy; identified coverage limitations to ensure proper adjudication.
- Recommended SOP updates to improve operational consistency and reduce errors.
Education
Associate of Arts - Business Administration and Management
Cerritos College
Norwalk, CASkills
- Decision-Making
- Team leadership
- Strategic Thinking
- Time Management
- Analytical Thinking
Accomplishments
- Managed and coached a high-performing team of 23 employees, enhancing audit accuracy, workflow efficiency, and cross-department collaboration.
- Led initiatives to correct and recover provider overpayments, surpassing the departments 2025 Payment Integrity recovery goal of $1M and strengthening internal controls.
Certification
- Ongoing education in healthcare operations, Medicare/Medicaid policy changes, and claims compliance
- Active participant in industry webinars, technology forums, and AI/RPA modernization discussions
Timeline
Manager Audit & Recovery/Provider Escalations
SCAN Health Plan
01.2017 - Current
Supervisor Claims Recovery & Provider Escalations
SCAN Health Plan
01.2016 - 01.2017
Claims Recovery Resolution Analyst
SCAN Health Plan
01.2015 - 01.2016
Provider Services Analyst, Senior
SCAN Health Plan
01.2010 - 01.2015
Senior Medical Claims Examiner
SCAN Health Plan
01.2008 - 01.2010
Associate of Arts - Business Administration and Management
Cerritos College
ADDITIONAL QUALIFICATIONS
- Strong operational leadership in multisite and remote/hybrid environments
- Knowledge of value-based care models, CMS audit requirements, and care management workflows
- Skilled in supporting geographically dispersed teams under evolving regulatory requirements
- Excellent communication, organizational, and relationship-building abilities