Summary
Overview
Work History
Education
Skills
Occupational Skills
Timeline
Generic

Myra Ramirez

Yuba City,CA

Summary

Dynamic professional with extensive customer service experience at Centene Corporation, skilled in HEDIS performance analysis and relationship management. Bilingual in Spanish, I excel in fostering trust-based relationships and delivering exceptional support. Proven ability to enhance provider engagement and improve performance metrics through effective communication and meticulous attention to detail.

Overview

22
22
years of professional experience

Work History

Home Care Aide

DNT In Home Care Inc. DBA Senior Helpers, Cameron
Cameron Park
04.2025 - Current
  • Provide companionship and emotional support to enhance client well-being including patients who are dealing with difficult diagnoses or end-of-life situations. Adhere to agency policies and procedures while providing home health services.
  • Maintain accurate records of client care and progress notes. Communicate effectively with families about client needs and concerns. Develop trust-based relationships with patients through compassionate communication techniques. Respect the dignity of all patients by maintaining confidentiality of their health information.
  • Perform light housekeeping duties including changing linens, laundry, vacuuming and dusting to ensure a safe and clean-living environment for all clients.
  • Assess home environment for safety hazards and made recommendations for improvement when necessary. Recognize emergency situations and implement appropriate procedures.
  • Assist clients with activities of daily living and personal hygiene such as feeding, bathing, incontinence care, dressing and grooming patients with limited physical abilities to support basic needs and/or to foster independence and well-being.
  • Deliver high level of assistance with cooking, meal preparation, shopping, and transportation to doctor appointments or other errands as needed.
  • Supervise personal hygiene, medication administration, simple prescribed exercises, such as daily physical therapy routines, and other activities of daily living.
  • Assist clients with mobility issues by helping them transfer in and out of bed, wheelchair or sitting to standing positions.

1. Senior Provider Engagement Account Manager

Centene Corporation: Health Net of CA
Hybrid Remote, CA
08.2024 - Current
  • Currently assigned a book of business consisting of 48 primary care physicians practicing primarily in San Francisco that involves retaining and managing these provider relationships, growing participation and improving performance and facilitating collaboration and navigation with our health plan(s).
  • Travel to these practices is often required to meet with providers at least once a week, otherwise check-in meetings are held via Zoom.
  • Assist providers in creating Action Plans with measurable goals to improve HEDIS performance and care gap closure, connect them with resources, training, support from internal subject matter experts.
  • Identify trends and outliers, prioritize agenda items, obtain buy-in, and drive accountability for improvement.
  • Facilitate provider performance discussions with providers utilizing various data reports reflecting previous and current year care gap closure performance numbers, targeted year HEDIS measures, RxEffect non-adherence risk details, Cozeva care gap registries, Hospital Admissions and health plan funding opportunities tied to HEDIS measure improvement efforts for participating providers and members.
  • Assist with submission of complex or escalated provider reported issues related to Contracting, Access to Care, Authorizations, Claims processing, HEDIS Care Gaps, Incentive Payments, etc.

2. Business Analyst II:CA Internal Operations Unit

Centene Corporation: CA Health & Wellness Plan
Remote, CA
03.2019 - 08.2024
  • Was a member of the initial pilot and successfully established CA Internal Operations Unit that launched support services to CA Provider Engagement Team effective 4/1/2019 to current.
  • Assisted in drafting workflow processes for Provider Engagement Field Reps to follow for submission of complex or escalated provider reported issues related to Contracting, Access to Care, Authorizations, Claims processing, HEDIS Care Gaps, Incentive Payments, etc.
  • Created SharePoint Intake Form template for Provider Engagement Team members to utilize to request assistance from CA Internal Ops Team (Sub-Team for P.E. Dept.).
  • Resolved claims related issues received via SharePoint intake forms; triaged OMNI Provider Outreach Workbasket items and CA Internal Ops Outlook Mailbox email inquiries; created, launched, and reported results to leadership for quarterly Provider Engagement Dept. Employee Pulse Survey as well as Physician Satisfaction Pulse Survey for Health Net, CalViva Health, Wellcare and CA Health & Wellness plans.
  • In Qtr. 2, 2022 initiated the bi-annual 'Provider Engagement Provider Satisfaction' survey with assistance from Qualtrics Team to measure provider satisfaction with their assigned health plan representative and the support they've received from their rep.
  • Created 'Provider Engagement New Request Intake Form' for all other Departments to utilize to request assistance from Provider Relations.
  • Created 'Claim Escalations Tracker' in April 2019 to document and track progress and work for provider reported claim issues.
  • On 7/1/2022 customized the existing Claim Escalations Tracker to be used by all other departments to enter, track and request assistance from Claims Team for provider escalate claim issues for All Health Net plans, CalViva Health, CH&W and Wellcare.
  • This involved working with Claims Team, Mgt, Firefly and Process Improvement Teams to document workflow and P&P for this new process to be used.
  • Also trained users on how to enter requests or document their work.
  • Actively identify process improvement opportunities and work with corresponding teams, including Provider Data Management, Coding Analytics, Benefit Configuration Team, Authorization Requirement Qualifications Grid & Trucare/Auth Team, Claims Team, Call Center, MHN, Corporate Front End Operations, Payment Integrity.

3. Provider Network Specialist I

Centene Corporation: CA Health & Wellness Plan
Sacramento, CA
11.2015 - 03.2019
  • Served as primary contact for assigned providers serving as a liaison between the provider and the health plan.
  • Conducting face to face or telephonic meetings with the providers documenting discussions, issues, attendees, and action items; investigating claims, credentialing and authorization issues on site and routing to the appropriate party for resolution when outside of personal scope of experience and access.
  • Initiated entry or change of provider related database information and oversee testing and completion of change requests.
  • Educate providers regarding policies and procedures related to referrals, credentialing and claims submission, web site education, EDI solicitation and problem solving.
  • Performed provider orientations, in the past this included writing and updating orientation materials.
  • Provided education and training as it may relate to HEDIS or healthcare related subjects and company initiatives.
  • Participated in the 'Dedicated Hospital Service Team' three-month pilot project under Erik Korolev commencing 1/20/2016.
  • In light of its success continued on the team until 3/31/18.
  • Under this team performed in-house root cause analysis and provided action plans for resolution of complex layered claims payment related issues.
  • Requested access to EMDEON, TruCare, AMISYS, FileNet, MicroStrategy and trained to utilize the systems outside of my scope of expertise.
  • Joined 'Claims Alignment Workgroup' under Sarah Walker representing Provider Relations from November 2016 to January 2017.
  • Worked on establishing communication and updating process flows for alignment of all departments in resolution of reported coding updates, claims payment or incorrect credentialing set-up issues.
  • Often identified the missing key corporate contacts to work with in order to complete systemic and process logic updates.
  • Championed for and obtained approval for HMS to switch eight major hospital providers onto the 'Disallowance Program' thus resolving a reported escalated provider issue of incorrect COB data and issues caused by Centene COB billing.
  • Maintained weekly updated Executive Summary Reports documenting description of issues, action plan outline and results.
  • Formed part of the Heritage Day Planning Committee under Jordan Lopez, implementing this tradition from HNET into CH&W Plan work force.
  • Recruiting talent for and coordinating set-up of the talent stations for the event.
  • Event took place August 18th, 2017.
  • Also participated in the Member Satisfaction Workgroup under Lisa Lambert in 2016, 'ED Diversion Workgroup' under Andrew Clark in 2017 and also the 'EPCO Steering Committee' to align contractual required updates per the Final Rule (Mega Reg.) on federal changes impacting Medicaid Managed Care effective 7/1/17.

4. Bilingual - Customer Service Representative II

Centene Corporation: CA Health & Wellness Plan
Sacramento, CA
11.2013 - 11.2015
  • Resolved inquiries via telephone in a call center environment.
  • Process written correspondence inquiries, such as primary care provider changes, and resolve secure email inquiries in a timely and appropriate manner.
  • Act as a liaison between members and health plan or providers, also for providers and health plan departments including investigating, resolving provider claims issues or routing to appropriate party for resolution.
  • Verify eligibility and manage care health plan benefit information for members and providers.
  • Instruct customers in utilization and navigation of plan and web portal features, such as locating forms, verifying eligibility, submitting claims or authorization requests.
  • Member of Employee Activities Committee (EAC) planning and coordinating volunteer activities.
  • EAC focuses on promoting employee collaboration and appreciation.
  • Member of Geo Pod 1 Group reporting network and service barriers and challenging issues to gain input and support from health plan departments.
  • Geo Pod collaborates with other departments to recommend and implement changes, request research into and obtain resolutions to current processes, resources and systems affecting the counties pertaining to the Geo Pod’s geographic area.
  • These counties include Sierra, Yuba, Plumas and Butte.
  • Comply with HIPPA laws.
  • Assisted Marketing & Communication Department working the California Health & Wellness Booth at Gold Country Fair/ Fairgrounds community event.
  • Completed Marketing Certification Training to learn guidelines and information regarding the plan and Medi-Cal program when conducting marketing activities on behalf of the plan.
  • Completed Sensitivity Training to prepare to service new member population of 'Seniors and Persons with Disabilities'.
  • Completed Compliance Training to understand company’s business ethics and conduct policies as well as waste, abuse and fraud avoidance.
  • Winner of the December 2014 Darby Trophy for Top Performer in Member and Provider Services.
  • Language Proficiency Assessment completed with a rating of ILR4 as an Advanced Professional obtained 12/13/2013 through CyraCom International, Inc.
  • Designated contact for St. Elizabeth’s Hospital for provider services and issues.

Bilingual Client Service Specialist

Verisight, Inc.
Folsom, CA
08.2011 - 11.2014
  • Focused on assisting and resolving retirement plan client’s direct requests and issues by answering incoming calls, following up with clients, and also via emails.
  • Maintained professionalism in both verbal and written communication and consistently demonstrate patience, good judgment and confidentiality with a desire to truly assist clients.
  • Act as a liaison internally with regards to client requests, including training employees and communicating with multiple departments to resolve inquiries.
  • Assist with special projects and support other employees as needed.
  • Knowledge and training of retirement plan administration.
  • Understand complex information with the ability to verbalize confidently, specifically in the review of retirement plan specifications and website navigation.
  • Use of MS Office, emphasis on Excel and Word.
  • Organize, prioritize and handle multiple projects.
  • Strong attention to detail, demonstrate excellent problem solving skills on a daily basis.
  • Also processed loan and withdrawal applications for eligibility and funding.
  • Translate/interpret documents.
  • Conducted educational and enrollment retirement plan presentations for participating employer groups.
  • Interpreted for financial advisory meetings.
  • Utilize Microsoft Office applications, DST, and Compass platforms.

1. Bilingual Benefit Helpline Specialist

Robert-Half Intl Staffing Agency: Healthy Families
Rancho Cordova, CA
08.2010 - 04.2011
  • Assisted English and Spanish speaking employees from participating employer groups with questions about their medical, dental, vision, flexible spending and health savings account coverage(s), enrollment and plan benefit details.
  • Advocated for employees in claims and appeals process analyzing claims for correct processing in accordance to employee’s benefit plan and submitting appeals when needed on their behalf.
  • Communicated with insurance carriers, providers, and employers to resolve coverage issues or questions.
  • Followed up with all issues and employees until resolved.
  • Documented and filed all information received.
  • At times assisted in interpreting enrollment or other documents to Spanish.
  • Complied with HIPPA laws.

2. Receptionist/Office Assistant

Robert-Half Intl Staffing Agcy: CA Housing Finance
Sacramento, CA
12.2008 - 01.2009
  • Can provide more detailed description of duties upon request.

3. Administrative Office Assistant

Robert-Half Intl Staffing Agcy: Clark Pest Control
Sacramento, CA
01.2008 - 05.2008
  • Can provide more detailed description of duties upon request.

4. Receptionist

Robert-Half Intl Staffing: Best, Best & Krieger
Sacramento, CA
12.2007 - 12.2007
  • Can provide more detailed description of duties upon request.

5. Bilingual Electronic Help Desk Specialist

Robert-Half Intl Staffing: First Data Govt Solns
McClellan, CA
08.2007 - 12.2007
  • Serviced English and Spanish incoming calls from Custodial or Non-custodial parents, employers and Local Child Support Agencies.
  • Utilized customer service CARE method to assist clients in caring, analyzing, resolving and exceeding their needs.
  • Verified payments being disbursed or received. Located lost or unidentified payments for immediate processing and disbursement to a Custodial parent.
  • Provided general information of how to enroll for payment submission or receipt methods such as Direct Deposit or Electronic Funds Transfers.
  • Enrolled Direct Deposit and Electronic Payment Card applications.
  • Assisted Data Entry Department entering data of new child support FL-191 forms or court order information to create a case file.
  • Assisted in data entry voiding process of disbursed checks returned from United States Post Office to alert Local Child Support agencies.

Bilingual Tele-Service Representative

Kaiser Permanente Medical Group
Sacramento, CA
07.2004 - 07.2007
  • Received incoming calls.
  • Utilized sight translation for scripts composed of medical intake questions to assist the Spanish speaking patient.
  • Followed script protocol and per medical urgency outcome booked appointments, transferred members to registered nurses or composed messages to their providers regarding medical health concerns.
  • Remained in compliance with all HIPAA laws and regulations.
  • Provided callers with general information of departments, facilities or providers.
  • Some filing, photocopying, faxing and typing for Manager and Nurses.
  • Completed Personalization of Customer Care, Medical Terminology, and Cultural Diversity training.

Bilingual Account Representative

Wittman Enterprises, LLC
Sacramento, CA
11.2003 - 05.2004
  • Worked in the collection of ambulance billing for fire departments, ambulance companies.
  • Collected and entered data, verified representation or eligibility for attorneys, health, and automobile insurance carriers.
  • Contacted hospitals involved in transport, and any other possible leads, to locate patient information useful for collecting dues.
  • Followed up for status with adjusters or health insurance carriers, submitting any documentation needed for insurance companies to determine benefits for patients.
  • Promptly executed EOBs, bankruptcy notices, hardship letters, and health insurance cards for Medi-Care, Medi-Cal, and other carriers.
  • Analyzed accounts for further review of insurance appeals, or delinquent accounts to outside collection agencies, or set up an installment plan with the patient in an attempt to collect dues.
  • Translated Spanish correspondence and calls.
  • Complied with each ambulance company’s individual policy requisites and HIPAA laws.

Education

Language Proficiency Assessment -

CyraCom International, Inc.
Tuscon, AZ
12.2013

Certificate of Completion - Healthcare Interpreter Training

UC Davis Health System
Sacramento, CA
06.2013

Computer Applications - Microsoft Suite 2007 and Introduction to Business Management

Heald College
Roseville, CA
04.2008

Diploma - Medical Claims and Billing

At-Home Professions
Fort Collins, CO
02.2005

High School Diploma - General Education and Honors English 11

Natomas High
Sacramento, CA
06.2001

General Education - Child Dev. courses

American River College
Sacramento, CA

Skills

  • Bilingual Spanish
  • Excellent Follow-up & Organization
  • Microsoft Office Works
  • Multi-task Oriented
  • Self-motivator
  • Strong Attention to Detail
  • Extensive Customer Service Experience
  • General Office Duties & Etiquette
  • Excellent Verbal & Communication
  • Cross-functional Oriented
  • Claims Billing & Collection Procedures and Guidelines
  • Medical Terminology
  • Personal Care Services
  • Relationship Management
  • HEDIS Performance Analysis

Occupational Skills

  • Bilingual Spanish
  • Excellent Follow-up & Organization
  • Microsoft Office Works
  • Multi-task Oriented
  • Self-motivator
  • Strong Attention to Detail
  • Extensive Customer Service Experience
  • General Office Duties & Etiquette
  • Excellent Verbal & Communication
  • Cross-functional Oriented
  • Claims Billing & Collection Procedures and Guidelines
  • Medical Terminology

Timeline

Home Care Aide

DNT In Home Care Inc. DBA Senior Helpers, Cameron
04.2025 - Current

1. Senior Provider Engagement Account Manager

Centene Corporation: Health Net of CA
08.2024 - Current

2. Business Analyst II:CA Internal Operations Unit

Centene Corporation: CA Health & Wellness Plan
03.2019 - 08.2024

3. Provider Network Specialist I

Centene Corporation: CA Health & Wellness Plan
11.2015 - 03.2019

4. Bilingual - Customer Service Representative II

Centene Corporation: CA Health & Wellness Plan
11.2013 - 11.2015

Bilingual Client Service Specialist

Verisight, Inc.
08.2011 - 11.2014

1. Bilingual Benefit Helpline Specialist

Robert-Half Intl Staffing Agency: Healthy Families
08.2010 - 04.2011

2. Receptionist/Office Assistant

Robert-Half Intl Staffing Agcy: CA Housing Finance
12.2008 - 01.2009

3. Administrative Office Assistant

Robert-Half Intl Staffing Agcy: Clark Pest Control
01.2008 - 05.2008

4. Receptionist

Robert-Half Intl Staffing: Best, Best & Krieger
12.2007 - 12.2007

5. Bilingual Electronic Help Desk Specialist

Robert-Half Intl Staffing: First Data Govt Solns
08.2007 - 12.2007

Bilingual Tele-Service Representative

Kaiser Permanente Medical Group
07.2004 - 07.2007

Bilingual Account Representative

Wittman Enterprises, LLC
11.2003 - 05.2004

Language Proficiency Assessment -

CyraCom International, Inc.

Certificate of Completion - Healthcare Interpreter Training

UC Davis Health System

Computer Applications - Microsoft Suite 2007 and Introduction to Business Management

Heald College

Diploma - Medical Claims and Billing

At-Home Professions

High School Diploma - General Education and Honors English 11

Natomas High

General Education - Child Dev. courses

American River College

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