Carmen D. Ortiz
Tampa,FL
Summary
Bilingual healthcare support professional with 20+ years of experience in Medicare, Medicaid, DSNP, long-term care, claims, authorizations, member advocacy, and care coordination support. Experienced in telephonic member support, identifying member needs, connecting individuals with appropriate resources, coordinating with care teams, and documenting accurately for compliance. Known for compassionate communication, process improvement, training peers, and helping members navigate complex healthcare systems. Seeking to contribute transferable care management, social needs navigation, and resource coordination experience as a Family Resource Specialist supporting families and care teams.
Overview
17
17
years of professional experience
Work History
Care Management Support Coordinator II
Centene Corporation
Tampa, USA
08.2022 - Current
- Provide direct telephonic support to Medicare, Medicaid and DSNP members by assessing the reason for contact, clarifying needs, and connecting members with appropriate plan resources and care management services.
- Support care coordination by facilitating communication between members, caregivers, providers, case managers and internal teams to help resolve barriers and promote timely follow-up.
- Create and route care management referral tasks, including CMPR, HRA, NAL, Medicare PS task routing, Post Discharge and Medicare Coordination workflows, based on member eligibility, risk level and program requirements.
- Perform benefit lookups using Sensentia and review eligibility or plan coverage information to help members understand available resources, including transportation, meals, caregiver support, DME and other non-clinical supports.
- Document member needs, outreach outcomes, barriers, preferred language, contact preferences and next steps in a clear, compliant and audit-ready manner.
- Train new agents on TruCare Classic and TruCare Cloud systems, inbound workflows, task routing expectations and documentation standards to support consistency and compliance.
- Develop and maintain training guides, process tools and personal tracking resources to improve onboarding, workflow efficiency and quality accuracy.
- Collaborate with leadership and cross-functional teams to support department transitions, member engagement strategies and process improvement initiatives.
- Use bilingual English/Spanish communication skills to deliver clear, compassionate and culturally respectful support to members and caregivers.
Bilingual Customer Service Quality Analyst
Anthem Blue Cross Blue Shield
Tampa, USA
01.2009 - 01.2022
- Supported Medicare, Medicaid and Long-Term Care lines of business by evaluating service quality, compliance accuracy and customer service delivery.
- Reviewed member interactions related to claims, authorizations, benefits and service concerns, helping identify opportunities to improve workflow accuracy and member experience.
- Provided feedback, coaching and peer support to agents to strengthen communication, problem-solving and adherence to regulatory requirements.
- Resolved member inquiries involving claims and authorization processes while maintaining professionalism, empathy and attention to detail.
- Collaborated with cross-functional teams to improve service processes, reduce gaps in resolution and support member satisfaction.
- Led quality assurance meetings and peer coaching sessions focused on accuracy, consistency and customer service excellence.
Education
Associate of Science Degree - Nursing
Hillsborough Community College
Tampa, FLMedical Esthetician Certification -
Certified Behavioral Health Technician Certification -
Skills
- Family and Member Support
- Benefit and Eligibility Research
- Resource Coordination
- Claims and Authorization Support
- Social Needs and Barrier Identification
- Documentation Accuracy and Regulatory Compliance
- Medicare
- Medicaid
- DSNP
- LTC Operations
- Interdisciplinary Team Collaboration
- Care Management Program Support
- Training
- Coaching
- Onboarding Support
- Telephonic Outreach
- Member Engagement
- Bilingual Communication
- Referrals
- Service Linkage
- TruCare Classic
- TruCare Cloud
- Sensentia
- Workday
- Microsoft Office
- Technology
- Microsoft Office Suite
- Excel
- Professional strengths
- Organized
- Approachable
- Detail-oriented
- Compliance-focused
- Committed to quality member support
Languages
- English
- Spanish
Relevant Experience
- Experience helping members and caregivers navigate healthcare systems, eligibility requirements, benefits, care management referrals and non-clinical support resources.
- Strong background in telephonic outreach, active listening, documentation, follow-up coordination and warm handoffs to appropriate internal departments.
- Familiar with identifying social and practical barriers such as transportation needs, caregiver support, medical equipment concerns, meal support, address or enrollment issues and access-to-care questions.
- Comfortable collaborating with interdisciplinary care teams and internal partners to support members with complex medical, behavioral health and long-term care needs.
- Bilingual English/Spanish communication skills and a member-centered approach that supports education, advocacy and system navigation.
Timeline
Care Management Support Coordinator II
Centene Corporation
08.2022 - Current
Bilingual Customer Service Quality Analyst
Anthem Blue Cross Blue Shield
01.2009 - 01.2022
Associate of Science Degree - Nursing
Hillsborough Community College