Miriam Gamez
Brownsville,TX
Summary
Healthcare professional with comprehensive background in case management coordination and quality analyst. Skilled in coordinating and streamlining client services to achieve optimal outcomes, with keen focus on team collaboration and adaptability. Known for reliability and results-oriented approach, leveraging critical thinking and organizational skills to meet changing needs.
Overview
26
26
years of professional experience
1
1
Certification
Work History
Quality Analyst II
Centene Corporation
02.2023 - Current
- Conducted comprehensive quality assessments to ensure compliance with regulatory standards and company policies.
- Collaborated with cross-functional teams to identify process inefficiencies and implement corrective actions.
- Developed and maintained detailed documentation of testing procedures and quality assurance protocols.
- Analyzed data trends to provide insights for continuous improvement initiatives across departments.
- Monitor, evaluate, and improve the performance of customer service advocates (CSA) in the Corporate Contact Centers.
- Help maintain high service standards, ensuring customer satisfaction, and driving continuous improvement within the contact center.
- Monitoring and Evaluation: Regular call and interaction monitoring to assess CSA performance.
- Evaluation of adherence to established articles and compliance with policies and procedures.
- Assessing CSAs’ ability to resolve customer issues effectively and efficiently.
- Scoring and Feedback: A scoring system to quantify agent performance based on predefined criteria.
- Constructive feedback provided to agents, focusing on areas of opportunity.
- Providing positive reinforcement for outstanding performance.
Call Analysis: Analyzing calls to identify trends, bottlenecks, and areas of opportunity. - Calibration and Consistency: Regular calibration sessions involving Quality Assurance Specialists, Leaders, and Operation Leadership to ensure consistency in scoring and feedback.
Key stakeholder collaboration to maintain a unified standard for quality assessment. - Technology Integration: Utilizing Quality Assurance software and tools for automated call recording, scoring, and reporting. Leveraging analytics tools to gain insights from the collected data.
- Compliance and Legal Adherence: Ensuring that agents comply with legal and regulatory requirements during interactions.
Auditing for compliance with privacy and data protection laws. - Continuous Improvement: Regularly reviewing and refining quality assurance processes to adapt to changing customer needs and industry trends. Encouraging a culture of continuous improvement and innovation within the contact center.
- Experience in with Qualtrics, Calabrio, Email & PET audits.
Customer Service Representative
Centene Corporation I
02.2022 - 02.2023
- Respond to telephone inquiries from members and/or providers within established timeframes utilizing current reference materials and available resources.
- Provide assistance to members and/or providers regarding website registration and navigation.
- Document all activities for quality and metrics reporting through the Customer Relationship Management (CRM) application.
- Process written customer correspondence and provide the appropriate level of timely follow up.
- May coordinate member transportation and make referrals to other departments as appropriate.
- Maintain performance and quality standards based on established call center metrics including turn-around times.
- Helped in nesting class as a SME.
- Was selected to move to COE claims for CA due to outstanding job performance.
- Delivered timely responses to customer inquiries through multiple communication channels.
- Resolved complex issues by utilizing problem-solving skills and product knowledge.
- Assisted in training new staff on customer service protocols and best practices.
- Implemented feedback mechanisms to enhance customer experience consistently.
Case Manager/Coordinator
Abundant Life Home Health
01.2005 - 02.2021
- Managed high caseloads effectively while maintaining close attention to detail and accuracy in documentation.
- Determined and coordinated appropriate level of care to meet individual patient needs.
- Answered incoming calls from clients, providers, social workers.
- Look for providers/attendants and send them to clients home to work.
- Clerical work, input data, filing and fax.
- EVV experience.
- Coordinated healthcare services to ensure comprehensive patient care plans.
- Developed and implemented individualized care strategies based on patient assessments.
- Monitored case progress and adjusted plans as necessary to meet evolving patient needs.
- Trained and mentored junior staff on case management best practices and protocols.
- Evaluated service delivery effectiveness and recommended improvements to enhance quality of care.
- Managed documentation processes to maintain compliance with regulatory standards and policies.
- Conducted thorough assessments of client needs, strengths, and risks to inform appropriate interventions and support services.
- Streamlined communication between clients, caregivers, and service providers to ensure timely access to resources.
- Collaborated with healthcare professionals to develop personalized care plans that addressed clients'' unique needs.
- Ensured compliance with federal, state, and agency regulations through meticulous record-keeping practices.
- Monitored progress towards goals regularly, adjusting case management plans as necessary for optimal success.
- Promoted diversity awareness within the workplace by initiating inclusive cultural competence training programs.
- Assisted clients in crisis situations by providing immediate intervention and connecting them with relevant resources.
- Reviewed caseworkers' client cases and made recommendations for additional actions and improvements.
- Coordinated services with other agencies, community-based organizations, and healthcare professionals to provide useful benefits to clients.
- Developed and implemented comprehensive case management plans to address client needs and goals.
Case Manager
APC Homemaker Service
01.2001 - 04.2002
- Determined and coordinated appropriate level of care to meet individual patient needs.
- Managed a caseload of clients.
- Fill out 2067s fax or mail to MCO/Social Workers.
- Look for providers and send them to clients home to work.
- Clerical work.
- Answer incoming calls from clients, providers and caseworkers.
Sales Representative
Convergys, AT&T
06.2000 - 11.2000
- Prepared and processed contracts and order forms for new and existing customers.
- Sale AT&T local service over the telephone.
- Input data
- Phone solicitation.
- Expanded sales to include mass market accounts.
Education
Associate of Arts - Social Work
Texas Southmost College
Brownsville, TX12-2024
Skills
- Friendly, positive attitude
- Working collaboratively
- Coordination
- Patient advising
- Communication skills
- Customer service
- Teamwork
- Time Management
- Computer Skills
- Audit processes
- Quality improvement
- Quality processes
- Customer focus
- Risk assessment
- Training material development
- Teamwork and positive attitude
- Developing quality standards
- Collaborative team player
- Documentation skills
- Team collaboration
- Training and onboarding
- Bilingual
Certification
- Certified Bilingual by Centene
Languages
Spanish
Full Professional
Timeline
Quality Analyst II
Centene Corporation
02.2023 - Current
Customer Service Representative
Centene Corporation I
02.2022 - 02.2023
Case Manager/Coordinator
Abundant Life Home Health
01.2005 - 02.2021
Case Manager
APC Homemaker Service
01.2001 - 04.2002
Sales Representative
Convergys, AT&T
06.2000 - 11.2000
Associate of Arts - Social Work
Texas Southmost College
Experience
I have more than 16 years of experience in Case Management and have worked with members before. Also very familiar with Medicare & Medicaid environment.
Education and Training
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