Mirella Ortiz Ureno
Modesto,CA
Summary
Healthcare operations representative with experience researching claims, verifying Medi-Cal eligibility, and resolving member inquiries. Skilled in Navigating multi-system environments (Shield Advisor, Facets) and maintaining accurate documentation in high volume workflows. Strong problem solving abilities, organized, adaptable, and bilingual in English and Spanish.
Overview
9
9
years of professional experience
1
1
Certification
Work History
Premier Concierge Representative
Blue Shield Of California Promise Health Plan
12.2024 - Current
- Navigate Facets Shield Advisor and internal portals simultaneously to reconcile account information and ensure correct routing.
- Review authorizations, clinical notes, eligibility, COB, and request proper documentation from provider offices, including CPT codes when provided by the provider.
- Investigate billing discrepancies by analyzing plan benefits, IPA/DOFR responsibility, COB order, and validation of billing outcomes to help correct financial responsibility.
- Communicate with provider offices to clarify DOFR guidelines and redirect billing to the appropriate IPA when services fall under delegated financial responsibility.
- Document all findings on claim outcomes. required documentation, and next steps while maintaining clarity, professionalism and audit ready accuracy.
- Assist members with continuity of care (COC), billing inquiries, eligibility questions and benefit coverage.
Customer Care Representative
Blue Shield Of California Promise Health Plan
06.2023 - 12.2024
- Entered detailed, HIPAA compliant notes to support internal workflows and downstream processes.
- Managed high volume calls while maintaining service quality and customer satisfaction.
- Follow Knowledge Base (KB) guidance and established workflows consistently while handling back to back calls, ensuring accurate issue resolution and adherence to quality standards.
- Manage escalations and pending cases by documenting, verifying eligibility/COB, and routing issues according to plan policy and internal workflows.
- Achieved strong QA performance through clear communication, workflow compliance, and accurate case handling.
Alarm Response/ Scheduling Specialist
Bay Alarm
08.2022 - 06.2023
- Created and managed new leads through inbound inquiries and outreach. Entering all details into HubSpot and ensuring sales reps had complete information before onsite visits.
- Provided customers with clear information about security system options, alarm response services and monitoring packages to prepare them for their onsite consultation.
- Documented all customer interactions and service needs with high accuracy to ensure smooth handoffs to sales, dispatch, and field teams.
Assistant Manager
Chilis's Bar and Grill
02.2017 - 03.2022
- Led Front of House and Heart of House operations, ensuring smooth daily service, quality standards, and guest satisfaction across multiple locations.
- Trained, coached, and developed new and existing staff in service standards, safety procedures, food quality, and shift operations.
- Oversaw cash handling duties including tills, cash drops, safe counts, and daily financial reconciliation.
- Conducted regular inventory counts, identified discrepancies, and placed supply orders to maintain accurate stock levels and reduce waste.
- Supervised day to day performance, resolved escalated guest issues, and maintained compliance with company policies.
- Assisted in recruiting, interviewing, hiring, and onboarding employees to maintain adequate staffing levels.
Education
High School Diploma -
Delta Charter High School
Tracy, CASkills
- HIPAA Compliance
- Shield Advisor & Facets
- Medi-Cal Plan Knowledge
- Documentation & QA Standards
- Attention to Detail
- Adaptability
- Problem Solving & Investigation
- Member and Provider Communication
- Organization & Prioritization
- Bilingual Communication (English & Spanish)
Certification
- Medical Billing & Coding Fundamentals - In Progress (Coursera)
- Google Data Analytics Certificate - In Progress (Coursera)
- IBM Data Analytics Professional Certificate - Starts March 2026
Languages
English
Spanish
Timeline
Premier Concierge Representative
Blue Shield Of California Promise Health Plan
12.2024 - Current
Customer Care Representative
Blue Shield Of California Promise Health Plan
06.2023 - 12.2024
Alarm Response/ Scheduling Specialist
Bay Alarm
08.2022 - 06.2023
Assistant Manager
Chilis's Bar and Grill
02.2017 - 03.2022
High School Diploma -
Delta Charter High School