Manager Medical

Ruben Jr. Del Rosario

Head of Companies and Medical Insurance (11 months)

Dr. Hamid S. Al-Ahmadi & Partners Co.

+63-966******* *********@*****.*** Antipolo, Calabarzon & Mimaropa

Experience

19 years of total experience

Mar 2018 - Jan 2019

(11 months)

Head of Companies and Medical Insurance

Dr. Hamid S. Al-Ahmadi & Partners Co. Saudi Arabia

Industry

Healthcare / Medical

Specialization

Healthcare - Nurse/Medical Support & Assistant

Role

Management

Position Level

Assistant Manager / Manager

- Liaise with insurance brokers to obtain information necessary to proceed with the purchasing of new insurance policies, renewing existing insurance policies, claiming from relevant parties, others as advised by Insurance Committee

- Coordinate internally with the management, including other business units to obtain required documents, authorized approval and payment process necessary to complete insurance policies

- Negotiate with insurance brokers regarding insurance plans, premium and coverage to leverage the efficiency of the company’s insurance policies

- Investigate, evaluate and settle claims, with relevant parties ensuring reasonable reimbursement from insurance companies

- Verify, analyze and summarize data related to insurance policies for Insurance Committee and proceed as advised by the Committee

- Provide advice and training and others on insurance matters

- Work with risk management team in terms of insurance policies and coverage

- Manage operations and productivity at an insurance company

- Create and modify procedures and documents related to policies

- Assist in claims management

- Identify and analyze risks associated with policies

- Achieve target budgets

- Minimize risk of financial loss

- Review insurance policies

- Review and Negotiate contracts with Insurance Companies

- Manage insurance data for reports

- Analyze statistical data, such as mortality, accident, sickness, disability, and retirement rates and construct probability tables to forecast risk and liability for payment of future benefits

- Determine premium rates

- Ascertain cash reserves necessary to ensure payment of future benefits.

- Other tasks as assigned

Feb 2016 - Feb 2018

(2 years 1 month)

Claims Supervisor

Andalusia Group for Medical Services - HJH Saudi Arabia

Industry

Healthcare / Medical

Specialization

Medical Insurance

Role

Others

Position Level

Assistant Manager / Manager

- Ensures the finalization of the inpatient and outpatient claims processing in a timely manner for all the assigned companies of the unit including the medical and the technical auditing and justification

- Ensures the timely submission of the finalized claims to the right company

- Inserts the companies’ policies and updates in the hospital information system

- Responsible for the claims submission, identifying needed codes

- Responsible for unit company’s policies administration and updates

- Participates and advise the companies and insurance accountants in the claims processing according to the policies approved by department director

- Claims Auditing for perfection before submission, Rejection review and reply, Reporting Process error requiring corrective action

- Monitoring / reporting team activity, performance and discipline, participates in training programs including the orientation of the new staff, Participates in the annual evaluation of the unit team members

- Share in the formulation of the unit plan and ensure staff commitment to the implementation of the approved plans

- Coordinates with the companies and insurance accountant the tasks assigned to the team members of the Unit

Aug 2002 - Jan 2016

(13 years 6 months)

Manager - Medical Operations

Bupa Arabia Saudi Arabia

Industry

Healthcare / Medical

Specialization

Medical Insurance

Role

Others

Position Level

Assistant Manager / Manager

Manager – Medical Claims Operations

- Review the output of different cell units within Claims Department (Upload, Input) to identify work load ready for distribution to the whole team.

- Complete tasks 100% Key Performance Index.

- Review assigned tasks before moving to the next cell unit.

- Update records for reference and reporting.

- Work proactively with other cell units to resolve issues that might cause process delay

- Inform external team members to help for external issues encountered

- Escalates serious issues encountered to superior for immediate actions and solutions.

- Liaises with the concerned Department Manager to recruit, select, train and develop productive medical staff (Pharmacists, Nurses of the caliber to achieve results and help develop careers within the department)

- Assist the department manager in his capacity to develop a robust strategy for the medical unit that aligns with the overall company vision, mission, values and strategic direction

- Provides daily and weekly reports to management

- Inform team members about work input and output

- Maintains a provider profile and takes steps to notice, escalate, and curb trend changes, abusive patterns, fraudulent practices, and sharp billing fluctuations in liaison with department manager

- Ensure effective risk management of the Medical Unit to achieve business objectives. This will also include continuous review and improvement of the medical processes and system in coordination with the department manager

- Batch analysis and utilization review to identify unwarranted services and unusual trend

- Evaluates the provider statements assigned for medical and technical consistency

- Review and identify areas of improvement and apply required action continuously improve the process to increase the overall efficiency

Senior Officer – Claims Quality

- Ensure the quality of technical and medical shortfall of the provider statements

- Send the Invalid Service Codes to Provider Relations team for validation and uploading in the agreement maintenance

- Maintained 100% elimination of all invalid system rejections over the final provider statements

- To achieve 2 days sub-KPI on provider statements

- Answers queries through email and phone calls regarding statements status and updates

- To train new personnel engaged with providers (Regional Managers, Provider Relation personnel and Hospital Audit Doctors – HAD)

- Prepare rework documents for sending to the Provider Relations (PR) team

- Applied rework done by PR and saving revised statements

Provider Relations In-House Clinic (IHC)

- Coordinates with In-House Clinics (IHC) being maintained by Bupa

- Review and analyze monthly and quarterly medication refill requests of the IHC

- Liaise with the supplier to send the monthly and quarterly requests of the IHC

- Creates contracts and agreements with suppliers for medical staff and medicines to be available in the IHC

- Communicates with the supplier on the availability of Doctors and Nurses inside the IHC

- Initiate and monitor payments made to the supplier of medical staff and medication refill on a monthly basis

Pre-Authorization Medical Officer

- Responsible for giving treatment or emergency medical care to the outpatient or in-patients by adjudicating each requests

- Examines the case sheet of every patient to complete treatment formalities and to judge clinical findings

- Works in coordination with consultants and specialists and follow the treatment for each patient

Aug 2000 - Aug 2002

(2 years 1 month)

Staff Nurse

San Juan Medical Center National Capital Reg, Philippines

Industry

Healthcare / Medical

Specialization

Healthcare - Nurse/Medical Support & Assistant

Role

Nurse

Position Level

1-4 Years Experienced Employee

Senior Staff Nurse – San Juan Medical Center

- Takes vital signs and performs head to toe assessment to patient

- Assists doctors and the rest of the medical team during rounds and endorsement

- Following and carrying out doctors’ orders

- Performs all kinds of intravenous therapy, cleaning and bandaging wounds, administering medications or injections.

- Observes and upholds the patients right of security, confidentiality and privacy

- Acted as shift supervisor during night shifts, to monitor the wards nurses’ availability and needs of the staff during their shift

Education

1999

University of the East Ramon Magsaysay Memorial Medical Center (UERM)

Professional License (Passed Board/Bar/Professional License Exam) in Nursing Philippines

CGPA

88.0 / 100.0

Licensed Nurse – Registered since June 2000 (Active License)

PRC Registration No. – 0336338

PRC Valid Until – June 26, 2019

Skills

Advanced

ICD-10 Coding, Quality Management, Microsoft Excel, Claims Management, Management Skills, Microsoft Office, Process Management, People Management, Project Planning And Management, Claims Audit

Languages

Proficiency level: 0 - Poor, 10 - Excellent

Language

Spoken Written

English

9 9

Additional Info

Expected Salary

Preferred Work Location

NCR – Philippines, Asia, Middle East, Singapore, Canada, Australia, USA

Other Information

I am a licensed nurse with more than 18 years of experience in medical, healthcare, and health insurance.

I believe I am capable and experienced for any position in claims and insurance department; I previously worked as Manager – Medical Operations at Claims Department at Bupa Arabia, as Claims Supervisor at Insurance Department at Hai Al Jamea Hospital, and now as Head of Companies and Medical Insurance at DHS Group, whilst working at those companies I learned a lot and I am now ready to progress my career further.

ICD-10 Coding, Claims Management, Claims Processing, Claims Audit, Claims Submission and Re-Submission, Pre-Authorization (Approval), Provider Relations, People Management, Reconciliation, Process Audit, Fraud Detection and Microsoft Office, are some of my experience and expertise.

I am responsible for managing a staff, composed of nurses and pharmacists of different nationalities. Training and supporting the team daily, as well as allocating their daily tasks and ensure that the quality of their completed tasks is within the standards set by the company.

My strong initiative, background and exceptional work ethic, combined with my ability to work well under pressure, allow me to play a crucial role in fast-paced, customer centered environments.

About Me

Gender

Male

Age

42 years

Telephone Number

(+63) 7900-7080

Address

Blk 2 Lot 13 Woodrow Hills Subd. Southgate, Brgy Dalig, 1870, Antipolo, Calabarzon & Mimaropa, Philippines

Nationality

Philippines

Contact this candidate