Sheila Pajar
San Pablo,CA
Summary
Experienced and highly-organized Program Analyst driven to contribute useful information to strategic decision making and program planning with effective data analysis. Highly effective at reviewing and validating data, conducting complex reviews and assessing program operations. Proficient in MicroStrategy and offering 8 years of experience in SharePoint; 6 years in program administration and 6 years in claims adjusting.
Overview
16
16
years of professional experience
Work History
Program Analyst/AGPA
Claims - State Contract Services
11.2017 - Current
- Accurately generate and maintain management reports to measure key performance/predictive metrics for claims adjusters, admin support and Utilization Review gatekeepers.
- Timely initiate and conduct research/studies and lead projects to address program's operational and management needs for efficiency and performance.
- Act as liaison between State Contracts and different programs statewide (such as: REM, HR Operations, Business Services, Internal Audit, Information.
- Governance and Public Records, Records Management Office) and other external stakeholders.
- Act as liaison/coordinator in Budget Planning Process with IT and Finance Department.
- Act as administrator of program's financial transactions and expense accounting.
- Provide assistance and support to leadership team as needed in scheduling interviews, hierarchy changes, assigning payment codes and putting together Power Point presentation for meetings.
- Maintain current knowledge of State Fund corporate developments, policies, and procedures affecting program management and staff operations to initiate and effectively perform administrative responsibilities and serve as resource to program management and staff.
- Keep accurate metrics and stats for adjusters according to DAU records.
- Create job aids and training materials in handling or auditing reports and using SharePoint as needed.
- Enhance program efficiency by streamlining processes and implementing data-driven improvements.
- Increase stakeholder satisfaction by delivering timely and accurate reports on program progress.
- Provide supervision, support and training to Claims Support in auditing of NCOA reports on regular basis.
- Timely and accurately review and audit Service Medical/Legal Reports to ensure Benefit notices and records are sent to all required parties timely according to Claims Procedures and Policy Guidelines.
- Timely perform COVID-19 Claims Review look-back and accurately document findings for 20+ files daily.
- Lead person with SharePoint for all of State Contract Services (SCS) - 6 locations statewide.
- Effectively organized 14 SharePoint sites which includes 6 SCS locations.
- Led SCS SharePoint migration in April 2019 during SharePoint migration (on Sunday) to ensure all documents, lists, libraries, Nintex Forms & Workflows, and Alert notifications migrated over to new platform; provided updates and necessary support, job aids and training materials to end-users for smooth and easy transition into application.
- Solely handled 2nd SharePoint migration in April 2022 for Vacaville office expanding into 2 sites for efficiency and to streamline access to sensitive/confidential records.
- Accurately maintain and organize all documents, lists and libraries on SharePoint; and ensure that old files are deleted according to Records Retention Policy.
Business Analyst/AISA (Training & Development)
Business Analysis Center In EPMO
08.2015 - 10.2017
- Effectively elicited and accurately documented business requirements for different department (such as Billing Center, Claims and other system applications) to provide tools supporting State Fund's core business operations with appropriate technology.
- Participated in User Acceptance Testing (UAT) writing Master Scenarios and reviewing and approving Details Test Scenarios (DTS) for Billing Center system.
- Supported software development projects by defining clear requirements and effectively communicating them to technical teams.
- Developed high-quality documentation to support training efforts, helping employees fully understand new systems and procedures.
- Performed gap analysis between existing systems or processes and desired state, identifying areas for improvement or enhancement.
- Conducted interviews with key business users to collect information on business processes and user requirements.
- Improved business processes by analyzing current practices and recommending optimization strategies.
Project Support Analyst/AGPA
Claims Business Technology Dept
03.2014 - 07.2015
- Effectively and timely monitored shared Inbox of 10-30 per day for handling of system updates and project requests.
- Timely reviewed project submissions and made determination to return, accept and referral for management's review approval.
- Effectively collaborated with stakeholders about successful roll-out of system enhancements and/or projects.
- Maintained accurate record keeping for all ECF and CARE related projects in Outlook and SharePoint.
- Accurately organized and reconciled open and closed files related to projects for future reference.
- Provided as back up in reviewing and processing of consultants' invoices for payments; gathering Claims weekly updates to Executives and publication of monthly newsletter to all users; and creating surveys for every major release of projects.
- Effectively managed and organized project documents on SharePoint for efficiency.
Utilization Review Coordinator/WCCA
Greater Bay Area Claims Utilization Review Dept
02.2014 - 06.2014
- Prioritized & authorized medical treatment according to established medical necessity and authority.
- Accurately identified and managed hundreds of scanned documents in accordance to District/Corporate guidelines.
- Ensured appropriate and timely referral of medical treatment requests to contracted vendor.
- Enhanced patient care quality by conducting thorough utilization reviews and coordinating with healthcare providers.
- Ensured compliance with regulatory guidelines by maintaining accurate documentation and records for all utilization review activities.
- Evaluated medical necessity criteria using evidence-based guidelines to ensure that services provided were both clinically appropriate and cost-effective.
- Managed approximately 30 incoming calls and faxes per day from medical offices.
- Managed complex cases involving multiple medical conditions, coordinating care among various specialists while adhering to strict timelines for decision-making.
- Evaluated medical necessity criteria using evidence-based guidelines to ensure that services provided were both clinically appropriate and cost effective.
Claims Adjuster/WCCA
Greater Bay Area Claims Services
09.2008 - 02.2014
- Provided timely and accurate liability decisions and benefit payments in compliance to labor codes, claims regulations and company policies.
- Effectively identified and resolved all issues for settlement of cases and saving employers thousands of dollars.
- Established and maintained timely, accurate and adequate estimates to 180 cases according to District/Corporate guidelines.
- Provided effective and professional public relations and customer service to internal and external customers.
- Ensured appropriate referral of files to other departments such as Legal, Subrogation, Fraud Investigations Unit and Premium Audit.
- Maintained compliance with state regulatory requirements through meticulous documentation and adherence to company policies.
- Achieved high customer satisfaction ratings by providing clear and timely communication throughout claims process.
- Conducted thorough investigations of complex insurance claims, gathering evidence and analyzing relevant documentation.
Education
Associate of Arts -
City College of San Francisco
San Francisco, CA01.1993
Skills
- Proficient in MicroStrategy, CARE, Hyperion, Oracle and State Fund Online
- Data Collection and Analysis
- Time Management
- Requirements Gathering
- Process Mapping
- User Acceptance TestingProblem Solving
- Decision Making
- Attention to Detail
- Analytical
- Advanced knowledge on SharePoint
- Proficient in Microsoft Office Suite
- Effective Oral and Written Communication
Accomplishments
As an adjuster:
Performance Award, 2013 and 2014
Top Performance for Closing Cases, 3Q 2013
Top Performance for Finalizations, Q1 and Q2 2010
As an Audit Technician:
Excellent Customer Service Award, 2007
Super Star for Exceptional and Outstanding Contributions Award, 2006
Achievement for Extraordinary Work Award, 2005
Corporate Excellence for Extraordinary Work Award, 2005
training
- SharePoint – Advanced for Designer and Site Admin Training, March 2019
- Business Analysis Training – Requirements Elicitation Workshop, September 2016
- Business Analyst Fundamentals, July 2016
- Franklin Covey Writing Skills Advantage Training, April 2016
- Project Management Essentials for the Unofficial Project Manager, September 2014
- SharePoint – Introduction for End Users and Site Admin Training, April 2014
- The 7 Habits of Highly Effective People, August 2014
- Certified Workers' Compensation Claims Adjuster, October 2008
Languages
Tagalog
Native or Bilingual
Timeline
Program Analyst/AGPA
Claims - State Contract Services
11.2017 - Current
Business Analyst/AISA (Training & Development)
Business Analysis Center In EPMO
08.2015 - 10.2017
Project Support Analyst/AGPA
Claims Business Technology Dept
03.2014 - 07.2015
Utilization Review Coordinator/WCCA
Greater Bay Area Claims Utilization Review Dept
02.2014 - 06.2014
Claims Adjuster/WCCA
Greater Bay Area Claims Services
09.2008 - 02.2014
Associate of Arts -
City College of San Francisco
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