Summary
Overview
Work History
Education
Skills
Certification
Timeline
Generic

GISELLE MATOS SANCHEZ

Arecibo

Summary

Strategic healthcare executive with over 10 years of experience driving operational excellence in medical claims administration, general services management, and clinical operations oversight. Recognized for leading high-performing, multidisciplinary teams and implementing process improvements that enhance efficiency, compliance, and financial performance. Adept at navigating complex regulatory environments, leveraging data analytics for decision-making, and delivering sustainable cost reductions while ensuring superior service quality and stakeholder satisfaction.

Overview

15
15
years of professional experience
1
1
Certification

Work History

Claims and Related Services Manager

International Medical Card
04.2021 - Current
  • Leads the units of Professional Claims, Institutional Claims, Audit, Reimbursements, Dental, USA, Walk-In, and Courier Services.
  • Ensures compliance with internal policies and local and federal regulations (CMS, HIPAA, OIG).
  • Implements service and productivity KPIs, identifying opportunities for cost savings and resource optimization.
  • Leads initiatives in inventory management and operational risk control, contributing to cost reduction.
  • Promotes continuous improvement and organizational transformation strategies, focused on quality and operational excellence.

Claims Supervisor (Plan Vital)

MMM Holdings
04.2015 - 04.2021
  • Supervised teams responsible for claims processing under Plan Vital, ensuring compliance with time and quality metrics.
  • Redesigned internal processes, reducing billing errors and claim denials.
  • Developed and delivered training programs to strengthen the team’s regulatory and operational knowledge.
  • Fostered interdepartmental collaboration to streamline workflows and enhance the experience of providers and members.
  • Prepared strategic reports for senior management with key performance indicators.

Clinical Affairs – Hospital Utilization

Medical Cards System, MCS
01.2011 - 04.2014
  • Evaluated hospital admissions and stays in accordance with medical and contractual criteria.
  • Validated medical authorizations to ensure appropriate use of resources.
  • Collaborated with physicians and clinical staff to justify hospital services.
  • Prepared utilization reports and hospitalization metrics for management and insurers.
  • Reviewed medical records to identify potential overutilization or inadequate practices.
  • Supported internal and external audits related to compliance with regulatory standards.

Education

PsyD - Clinical Psychology

Pontifical Catholic University of Puerto Rico
Arecibo
05-2027

Master of Science - Psychological Counseling

Carlos Albizu University
San Juan
01-2022

Bachelor of Science - Public Health

Ana G. Méndez University
Bayamon
08-2019

Skills

  • Systems Proficiency: Inmediata, Power MHS, CRIS, CCMS Qnxt, Onbase, Etime (ADP), MHK, R-Credentials, RCM, SQL Server Management
  • Microsoft Office: Excel, Word, PowerPoint, and Teams
  • Leadership: Proven ability to lead and develop high-performing multidisciplinary teams
  • Conference Speaker: Skilled in delivering professional presentations and speaking at conferences

Certification

  • HIPAA Law – Control and Regulation
  • Medical Billing – PMB
  • RAF V28 (HCC)
  • FWA (Fraud, Waste, and Abuse)
  • EMTALA
  • HEDIS, AHA, CHARA Measures
  • CPR and First Aid
  • Project Management Professional (PMP – in progress)

Timeline

Claims and Related Services Manager

International Medical Card
04.2021 - Current

Claims Supervisor (Plan Vital)

MMM Holdings
04.2015 - 04.2021

Clinical Affairs – Hospital Utilization

Medical Cards System, MCS
01.2011 - 04.2014

PsyD - Clinical Psychology

Pontifical Catholic University of Puerto Rico

Master of Science - Psychological Counseling

Carlos Albizu University

Bachelor of Science - Public Health

Ana G. Méndez University

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GISELLE MATOS SANCHEZ