Carmen Montes-Torres
Casselberry
Summary
Experienced healthcare and specialty pharmacy professional with 15+ years of experience supporting specialty pharmacy operations, insurance verification, medical and pharmacy claim research, prior authorizations, refill processing, copay assistance programs, and patient support services. Proven background in call center operations, manufacturing communications, billing support, and cross-functional collaboration within fast-paced healthcare environments. Adept at resolving insurance and claims issues, supporting patient access to medications, and delivering exceptional customer service while maintaining compliance and operational accuracy.
Overview
21
21
years of professional experience
1
1
Certification
Work History
Training Specialist / QA Analyst
Elligo Health Research
Austin, TX
03.2021 - 02.2026
- QA Analyst
- Conducted quality reviews and audit documentation supporting healthcare operations and compliance standards.
- Collaborated with cross-functional teams to investigate quality and operational issues, including root cause analysis and corrective action support.
- Assisted with SOP documentation, compliance reviews, and process improvement initiatives in regulated healthcare environments.
- Maintained documentation accuracy and supported operational compliance with internal and external standards.
- Training Specialist
- Facilitated onboarding and operational training for healthcare employees in fast-paced clinical and support environments.
- Delivered HIPAA and compliance training supporting over 300 employees.
- Supported LMS administration and Jira ticket management processes.
- Partnered with stakeholders to identify operational training needs and improve employee readiness.
Training Specialist
Kroger Specialty Pharmacy
Lake Mary, FL
12.2015 - 01.2021
- Developed and facilitated onboarding training for specialty pharmacy employees across multiple operational locations.
- Created training materials and job aids related to specialty pharmacy workflows, insurance verification, and operational processes.
- Collaborated with operational leadership to improve employee readiness and support pharmacy service excellence.
- Conducted training needs assessments to support operational efficiency and service quality.
- Served as liaison supporting pharmacy operations and certified trainers across multiple locations.
Insurance Verifier
Kroger Specialty Pharmacy
Lake Mary, FL
12.2014 - 12.2015
- Researched pharmacy and medical claims to support prior authorization approvals and medication access.
- Verified patient insurance benefits, eligibility, and coverage details for specialty medications.
- Coordinated with physician offices to obtain clinical documentation required for prior authorization submissions.
- Performed refill and authorization follow-up activities with insurance providers and PBMs.
- Assisted patients with copay assistance programs and secondary insurance benefits to reduce out-of-pocket costs.
- Conducted welcome calls and provided patient education regarding insurance benefits and pharmacy services.
- Initiated test claims to validate approval or denial outcomes and support claims resolution.
- Maintained accurate documentation within pharmacy systems and patient accounts.
Pharmacy Technician
Kroger Specialty Pharmacy
Lake Mary, FL
06.2007 - 12.2015
- Adjudicated pharmacy claims and resolved insurance claim rejections within CPR+ systems.
- Processed copay payments, insurance verifications, and patient billing support activities.
- Collaborated with PBMs and insurance providers to resolve prior authorization and claim-related issues.
- Assisted patients with payment processing, refill coordination, and claims support.
- Supported high-volume call center operations while delivering exceptional patient service.
Triage Specialist
Kroger Specialty Pharmacy
Lake Mary, FL
03.2005 - 06.2007
- Processed incoming physician documentation and patient information supporting specialty pharmacy workflows.
- Coordinated with internal sales and operational teams to resolve missing information and expedite processing activities.
- Supported call center operations and interdepartmental communications in high-volume environments.
Education
Bachelor of Arts - Fashion Design and Development
Fashion Institute of Technology
New York, NYSkills
- Specialty Pharmacy Operations
- Pharmacy Claims Research
- Medical Claims Research
- Insurance Verification
- Prior Authorization Processing
- Refill Billing Support
- Medical Billing Support
- Copay Assistance Programs
- Manufacturer Communications
- Patient Support Services
- Call Center Operations
- PBM Coordination
- Benefit Verification
- Claims Adjudication
- HIPAA Compliance
- Customer Service
- Salesforce
- CPR
- Documentation Management
- Bilingual English/Spanish
Certification
Florida Notary Public
Languages
Spanish
Full Professional
Timeline
Training Specialist / QA Analyst
Elligo Health Research
03.2021 - 02.2026
Training Specialist
Kroger Specialty Pharmacy
12.2015 - 01.2021
Insurance Verifier
Kroger Specialty Pharmacy
12.2014 - 12.2015
Pharmacy Technician
Kroger Specialty Pharmacy
06.2007 - 12.2015
Triage Specialist
Kroger Specialty Pharmacy
03.2005 - 06.2007
Bachelor of Arts - Fashion Design and Development
Fashion Institute of Technology