Bonjovi Español

BONJOVI ESPAÑOL PH-1 Hanjin Village Fiesta Communities, Nagbunga, Castillejos, Zambales 2208 - |- PROFESSIONAL SUMMARY Versatile and dependable healthcare support professional with extensive experience in claims processing, medical coding, and insurance administration. WORK EXPERIENCE Charge Description Master – Revenue Integrity Analyst I Conifer Health Solutions January 16, 2023 – September 15, 2023 • • • • • • • • • • Maintain and update the Charge Description Master (CDM) to reflect accurate, complete, and compliant charge codes, descriptions, and pricing. Collaborate with clinical departments, coding, billing, compliance, and IT teams to evaluate and optimize charge capture workflows. Monitor charge capture for completeness and timeliness across departments; identify missed or late charges and investigate root causes. Conduct audits and charge reviews to ensure billing accuracy and adherence to regulatory requirements. Support implementation of new services and procedures by ensuring appropriate charge codes and pricing are in place. Analyze trends in charge capture, denials, and reimbursement to identify areas of improvement or revenue leakage. Work with revenue cycle teams to implement corrective actions and process improvements based on audit and analytical findings. Keep abreast of regulatory updates (CMS, AMA, CPT/HCPCS changes) that impact billing and charging practices. Provide education and support to departments regarding charging practices and documentation requirements. Prepare reports and present findings to leadership on charge-related metrics and compliance issues. PhilHealth Claims Insurance Officer Sta. Cecilia Medical Center July 1, 2019 – December 15, 2021 Claims Processing and Management: • • • • Oversee the end-to-end preparation and submission of PhilHealth claims (inpatient and outpatient). Validate completeness and accuracy of all required claim documents (CF1, CF2, CF3, waiver forms, medical abstracts, etc.). Monitor eClaims transactions and ensure timely submission and electronic encoding in the PhilHealth portal. Review and approve claims before final submission to reduce denial rates and RTH (Return-To-Hospital) cases. Compliance and Documentation: • • • Ensure compliance with updated PhilHealth circulars, rules, and benefit packages. Coordinate with physicians, nurses, and medical records to gather and verify clinical documentation required for claims. Stay current with PhilHealth billing regulations and changes in the case rate system or policy updates. Monitoring and Reconciliation: • • • Track claim status (approved, returned, denied, in-process) and ensure timely follow-up on problematic claims. Address returned claims by analyzing reasons for RTH or denials and initiate resubmissions with corrective actions. Reconcile PhilHealth claim payments with billing records in coordination with the Accounting Department. Reporting and Coordination: • • • Prepare regular summary reports on claims submitted, approved, denied, and collected. Provide management with analytics on claim performance and reimbursement trends. Liaise with PhilHealth regional offices to resolve disputes and clarify policy issues. Team Oversight and Support: • • Supervise junior staff or claims clerks, ensuring proper task delegation and training. Assist in process improvement initiatives related to billing and insurance claims. Hospital Claims Processing Staff President Ramon Magsaysay Memorial Hospital March 22, 2017 – June 30, 2019 Claims Preparation and Filing: • • • Prepare and compile all necessary documents for PhilHealth claims submission, including CF1, CF2, CF3, operative reports, and medical abstracts. Encode claim details into the PhilHealth eClaims system accurately and completely. Submit claims within the required filing period to avoid delays or denials. Documentation and Validation: • • • Coordinate with admitting, nursing, and medical records departments to ensure accurate and complete documentation. Validate patient eligibility, case rates, and applicable benefits prior to claim submission. Check accuracy of RVS (Relative Value Scale) and ICD codes based on services rendered. Claims Monitoring and Follow-up: • • • Track status of submitted claims (approved, denied, returned) and update internal logs or systems. Monitor aging of claims and prioritize follow-up on pending or returned transactions. Assist in the correction and resubmission of RTH (Return-to-Hospital) or denied claims. Compliance and Coordination: • • • Ensure all submissions comply with the latest PhilHealth circulars, policies, and requirements. Maintain organized and secure files (physical and digital) of all submitted and processed claims. Assist in audit activities related to PhilHealth claims when needed. Reporting and Support: • • Generate and submit daily/weekly reports on claims submitted and their current status. Support the billing and finance teams in reconciling PhilHealth payments and remittances. EDUCATION Subic Bay Colleges Inc. Diploma in Computer Programming / Computer Hardware Servicing 2011 – 2012 SKILLS • Claims Processing • Medical Coding (ICD-10, CPT, HCPCS) • Healthcare Revenue Cycle Management • Claims Auditing & Review • Insurance Verification & Documentation • EMR/EHR Systems Familiarity • Charge Description Master (CDM) Understanding • Attention to Detail & Accuracy • Critical Thinking & Problem Solving • Time Management & Multitasking • Remote Work & Team Collaboration • Microsoft Office (Excel, Word, Outlook) • Data Entry & Record Keeping • Communication & Interpersonal Skills CERTIFICATIONS & TRAININGS • ICD-10 Coding Certification (PhilHealth SHIA Training Room, Pasig City – DOH) • National Rabies Information System (NARIS) (San Fernando, Pampanga – DOH) • Integrated Leprosy Information System (ILIS) (San Fernando, Pampanga – DOH) • Bizbox Inc. (Hospital & PhilHealth Information System Training) (Iba, Zambales) • PhilHealth Claim Form 4 Implementation / EPCB (PhilHealth RO3, San Fernando, Pampanga) • Hospital Claim Review & Discussion (LHIO Iba, Zambales) • EF SET 71/100 C2 PROFICIENT REFERENCE Daniel A. Mora Administrative Officer IV--