ROXANA RAY
Corona
Summary
Detail-oriented healthcare professional with 5+ years of experience at OptumRx supporting complex pharmacy claims research, eligibility verification, and member issue resolution within managed care environments. Proven ability to analyze benefit determinations, and collaborate with cross-functional teams to resolve complex cases accurately and timely. Highly skilled in documentation, compliance, and written/verbal communication in fast-paced, regulated healthcare settings. Strategic and persuasive with several years of experience working in customer-facing environments. Accustomed to using tactful communication and active listening to creatively solve problems achieve positive outcomes.
Overview
2026
2026
years of professional experience
Work History
Senior Customer Service Representative
OptumRx Pharmacy Services
Costa Mesa
10.2019 - Current
- Research and resolve complex pharmacy claims, eligibility, and benefit issues for members across multiple managed care plans.
- Investigate rejected prescriptions, prior authorizations, accumulators, balance inquiries, and medication cost discrepancies.
- Analyze plan documents, system data, and claim history to determine root causes and identify resolution paths.
- Document findings clearly and accurately in internal systems in compliance with company policies and regulatory standards.
- Collaborate with internal departments to coordinate case resolutions and ensure accurate outcomes for members and providers.
- Communicate resolutions verbally and in writing with professionalism and clarity.
- Provide backup support during peak periods while maintaining high accuracy and productivity.
- Utilize systems including RxClaims, Optum IRIS, Optum Navigator, Advocate Central, Citrix, Microsoft Office, and Teams.
Regional Support Center Representative II / Team Lead
Charter Communications (Spectrum)
01.2017 - 01.2019
Lobby Ambassador
Gulfstream Aerospace
01.2012 - 01.2017
Sales Associate
Macy's
01.2011 - 01.2012
POET Certified Training Facilitator
OptumRx Pharmacy Services
- Assisted with new hire training, onboarding, and knowledge reinforcement.
- Documented class participation and provided feedback to leadership.
- Identified performance gaps and implemented improvement strategies.
- Coached employees on best practices and compliance standards to support professional growth.
Subject Matter Expert (SME)
OptumRx Pharmacy Services
- Serve as a resource for coworkers regarding claims research, mail-order pharmacy processes, and plan benefits.
- Assist team members with complex cases requiring deeper investigation and policy interpretation.
- Create internal communications and reminders to improve First Call Resolution (FCR), sentiment, and NPS metrics.
- Support quality and performance improvement initiatives.
PBM/PCS Correspondence Representative
OptumRx Pharmacy Svcs
Education
Associate of Arts - General Studies (Behavioral Health Emphasis)
El Camino College
Compton, CAHigh School Diploma -
Somerset High School
Bellflower, CASkills
- Appeals & Grievance Research Support
- Claims & Eligibility Investigation
- Medicare & Medicaid plans
- Policy & Process Adherence
- CMS-style documentation and case notes
- Analytical Problem Solving
- Cross-Functional Collaboration
- Written & Verbal Communication
- Confidentiality & HIPAA Compliance
- Proficiency with Windows PC applications, Microsoft Word , Microsoft Teams, Microsoft Outlook, Rxclaims, Nice which includes the ability to navigate multiple programs and learn new and complex computer system applications
- Chat communications experience
- Data Entry
Timeline
Senior Customer Service Representative
OptumRx Pharmacy Services
10.2019 - Current
Regional Support Center Representative II / Team Lead
Charter Communications (Spectrum)
01.2017 - 01.2019
Lobby Ambassador
Gulfstream Aerospace
01.2012 - 01.2017
Sales Associate
Macy's
01.2011 - 01.2012
POET Certified Training Facilitator
OptumRx Pharmacy Services
Subject Matter Expert (SME)
OptumRx Pharmacy Services
PBM/PCS Correspondence Representative
OptumRx Pharmacy Svcs
Associate of Arts - General Studies (Behavioral Health Emphasis)
El Camino College
High School Diploma -
Somerset High School