Sheila Gamueda

• Researched, analyzed, managed and reviewed 22-32 medical and/or dental cases per day.
• Update relevant medical case data on files as needed.
• Subject matter expert and the primary point of contact for Third-party payor member groups in the medical management team.
• Assisted in case/review audits and reporting needs requested internally by senior management and/or by external organizations.
• Knowledgeable of Medicare/Medicaid policies and procedures for medical case reviews.
• Established and maintain solid relationships with internal departments : Sales team, Brokers, Customer Service team, Underwriting, Account Executives.
• Participated in completing data analysis to identify significant administrative findings.
• Developed creative solutions and processes to resolve areas of perceived deficiency.
• Recommended solutions to improve department workflows and administrative procedures.
• Evaluated diverse departmental systems to identify workflow, communication and resource utilization issues.
• Conducted thorough reviews of operations to devise and deploy improvement strategies.
• Evaluated current processes to develop improvement plans.
• Produced detailed and relevant reports for use in making business decisions and for the medical director’s/medical team decisions.
• Recommended standard operational improvements based on tracking and analysis of department data.
• Researched and compiled member’s medical and benefit data to present the findings for the medical review board team which assisted in their final medical determinations on high dollar medical cases.
• Participated in process improvement initiatives for the team as needed.

• Researched and analyzed member’s medical and benefit cases previously sent to the medical directors/nurses/dentists.
• Handled 10-25 calls/emails per day to address customer inquiries, issues and concerns. Delivered exceptional level of customer service to each customer by listening to concerns and answering questions. Highly organized with successful multi-tasking skills and time management skills.
• Process medical reviews, recognizing any discrepancies and promptly addressing for resolution.
• Assisted FACETS IT team in system testing and validation problems to provide normal program functioning for the medical management department. Collaborated with them to enhance supportability and identify performance bottlenecks. Additionally, estimated work hours and tracked progress using Scrum methodology during the testing phase.
• Collaborated with engineers, system analysts, and programmers regarding project capabilities and limitations to deliver optimal functionality for the medical management department. Assist in the data modeling, performance, integration testing, and planning exercises for system and business process rollouts.
• Played major role in CCMS and FACETS systems modifications to improve functionality for the medical management department.
• Documented and provided recommendations on department workflows to senior management; and assisted in creating the FACETS department user manual.
• Assisted in reporting needs and audits requested internally by senior management or by external organizations, such as Utilization Review Accreditation Commission (URAC) Organization.
• Communicated of any fraud medical/dental cases to medical directors and senior management.
• Established and maintain solid relationships with other internal departments such as Brokers, Sales team, Customer Service management team on urgent medical reviews.
• Coordinated and trained team on deployments of new systems/applications, feature updates and fixes.
• Assisted senior management in the development of team’s Standard Operating Procedures (SOP). Analyzed work to generate logic for new systems and procedures.
• Developed training materials and trained team on new systems, applications, and new medical management SOP/workflows.
• Participated in continuous improvement by generating suggestions, engaging in problem-solving activities to support teamwork.
• Delivered exceptional level of service to each customer by listening to concerns and answering questions.
• Proved successful working within tight deadlines and fast-paced atmosphere.
• Used Microsoft applications to create documents, spreadsheets and other communications.
• Resolved conflicting issues between different departments regarding medical reviews.
• Conducted research, gathered information from multiple sources and presented results.
• Assisted in projects and analyzed data to identify opportunities for improvements.
• Performed duties in accordance with applicable standards, timelines, policies and regulatory guidelines to promote good customer satisfaction.
• Developed and implemented performance improvement strategies and plans to promote continuous improvement.
• Eliminated downtime and maximized revenue by providing top project quality control.
• Resolved conflicts and member issues to provide exceptional customer service.
• Worked closely with other internal departments such as Brokers, Sales team, Customer Service management team, Account Executives, Corporate Legal team on urgent medical reviews.
• Participate with management in continuous improvement of the team’s productivity processes and to help eliminate any downtime in the daily workflow. Engaging in problem-solving activities to support teamwork.

• Managed and the subject matter expert for the Diabetes Mellitus member files and Paradigm newborn member cases.
• Knowledgeable of Medicare/Medicaid policies and procedures for medical reviews.
• Managed ASO/NON-ASO/FULLY INSURED member plans.
• Reviewed, coordinated submission and processed urgent, current and retrospective dental cases and medical necessity cases.
• Reviewed benefits paperwork for accuracy and completeness for the medical review team and for the medical director’s review board team.
• Trained new team members in policies and procedures and offered insight into best ways to manage job tasks and duties.
• Resolved issues and inquiries for member participants regarding their medical and dental benefits via telephone and/or email requests.
• Managed, planned and coordinated the required monthly "Continued Education In-services" for the medical management department.
• Assisted in the optimization and implementation of the company-wide development of CCMS system and business processes resulting in profitable outcomes for medical management department. Assisted in the department planning and performed system testing to uncover bugs and troubleshoot any issues prior to application launch.
• Handled 15-25 calls/emails per day to address customer inquiries and concerns.
• Served customers (internal and external) and followed outlined steps of service.

• Complete the day-to-day administration for the following programs: medical plan, dental plan, vision plan, FMLA, Life insurance, STD, LTD, Flexible Spending & Health Savings Account, 401K & Pension, and COBRA administration.
• Assist in the preparation and drafting of the company’s Summary Plan Descriptions annually. • Assist with senior management in the development of all HR communication tools & resources to enhance understanding of the company’s benefits package.
• Interfaced and provide HR support to Employee Relation Managers, Recruiters, Payroll managers, Compensation managers, and to all department managers within the Great West Healthcare corporation.
• Served as the primary benefits administrator/HR generalist contact to all levels of employees/managers.
• Engaged in the department system developments, special projects or other duties as assigned.
• Subject matter expert for the benefits administrators on the new HR SAP system. Provided troubleshooting and technical assistance in the use of the HR SAP system.
• Analyze and assisted with recommendations on current employee benefits to the HR senior management; evaluating the use, services, coverages, effectiveness, cost, plan experience and competitive trends in benefit programs.
• Maximized team knowledge and productivity by training, monitoring and directing employees in application of best practices and regulatory protocols.
• Reviewed existing policies and procedures to make recommendations for enhancing the department’s work productivity, recruitment, hiring processes and talent management.
• Liaised between management and employees to deliver conflict resolution, alleviate problems and interpret compensation and benefits policies.
• Analyzed issues and employed improvement processes.
• Conserved time and improved workflows by handling special projects and emergency solutions.
• Advocated for employees and counsel supervisors/managers to identify and resolve conflicts.
• Actively listened to employee’s requests, confirming full understanding before addressing concerns.
• Partnered with senior leadership to establish and develop corporate and HR policies and procedures.
• Conducted annual salary surveys and developed, analyzed and updated company salary budget spreadsheets.
• Completed projects on time and under budget while resolving complex issues for senior HR leaders.
• Improved customer service rankings by quickly resolving issues to improve overall satisfaction.

• Helped physicians complete procedures such as lumbar punctures by supporting patients and organizing necessary supplies.
• Transported patients between unit rooms and scanning locations for diverse procedures.
• Collaborated with nurse preceptors and other medical staff to achieve quality patient outcome goals.

Managed and care for 5-10 patients per shift.
• Researched different diagnoses to become familiar with presentation and treatment protocols.
• Administered medications via oral, IV and intramuscular injections and monitored responses.
• Administered close patient care, checked vital signs and monitored telemetry.
• Updated patient charts with data such as medications to keep records current and support accurate treatments.
• Cared for each patient according to care plan and physicians' instructions.
• Built rapport with patients and members of patients' support systems.
• Kept optimal supply levels in treatment rooms, triage and other areas to meet typical patient loads.
• Coordinated meal and snack deliveries, assisted with feeding and charted intake for review.
• Completed medical facility experience while under supervision of qualified staff.
• Assisted with nurse preceptors on phlebotomy tasks to obtain needed biological specimens for laboratory testing.
• Assisted patients with personal hygiene requirements and monitored conditions to update nursing staff.
• Monitored each patient to meet appropriate care and document status changes.
• Worked alongside experienced nursing professionals to learn new procedures.
• Changed out and monitored bandages, catheters and IVs.
• Delivered exceptional care to patients by helping with mobility and daily living requirements.