Experience — Holden Malabuyoc

About Me

I am Holden Malabuyoc, highly organized and motivated professional with extensive experience in claims management and in depth knowledge about insurance and marketing. I have 11 years’ experience in the insurance industry with almost 5 years’ experience in Insurance Company as Claims Specialist and 7 years in managing the insurance department of medical and diagnostic clinics all over U.A.E. I continuously strive to ensure departmental goals and standards are upheld. I possess an analytical mind, and very much a team player who thrives in a stimulating a dynamic environment. I possess excellent communication skills both oral and written. My goal is to continue learning, exercise and broaden my skills to progress in my future position within the organization.

I graduated from one of the best school in the Philippines which is De La Salle University as Bachelor of Science in Business Administration Major in Marketing and Advertising Management and advanced studying online course as Project Manager and Human Resource at Career Match London, United Kingdom.

I am currently looking for an opportunity where I can apply and develop my skills as a Professional. I would welcome the opportunity to further discuss my skills and the position you would offer. If you have questions or would like to schedule an interview, please contact me at my mobile number +639983736484or +639165881992 or by e-mail at hym.mka@gmail.com or insuranceholden@gmail.com.

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Experiences

• Resolves the insurance issues of the clinic which includes, empanelment for insurance companies, rejections, pending receivables and other guidelines needs to be followed for both insurance companies and health authority.
• Teach the doctors on how to provide proper documentation on the claims.
• Advise the clinic owners how to increase the revenue of the clinic.
• Trains the insurance staff with regards to authorization and coding guidelines
• In charge of coding the clinic claims in order to reduce the rejection.
• Monitors the insurance work within the Corporation to ensure that the best coverage is obtained and that all claims are settled in a prompt manner.
• Leads studies for the existing policies concerning all insurance issues claims and tenders
• Anticipates any changes and follows up any renewal of insurance policies
• Reviews and Monitors the process of insurance claims and follows up significant investigations and negotiations and refers major cases to superiors to ensure prompt settlement
• Attends and responds to any insurance queries raised by various departments
• Resolves issues/concerns and leads meetings with the loss adjusters/surveyors.
• Participates in any insurance tendering as required.
• Arranges additional insurance as required due to changes in operational circumstances and administrates any renewal of the policies concerning insurance issues.
• Reviews, checks and Scrutinizes internal and external correspondence relating to all insurance matters to ensure accuracy, completeness and thoroughness of information.

• Managing all the aspects related to insurance for Menalabs Medical Laboratory and Biotech Al Ain and supervising their activities to achieve organizational objectives and target.
• Provide leadership and direction to direct reports for Menalabs and Biotech Al Ain
• Reports to the COO the progress and provides alternative solutions to uplift and maximize the revenue and profit of the company.
• Maintain Highest Levels of Corporate relationship of Existing Customers to enhance Business Development & Retention.
• Develop and implement a department strategy, set departmental and operational goals and initiate measures to reach these goals and to improve the overall department performance
• Responsible for a result-oriented management and development of people and resources, including provision of a strong day-to-day leadership presence involving resource allocation, monitoring, reporting, and conducting regular staff meetings • Initiate, develop, implement and ensure adherence to policies and procedures
• Review and assess programs and project proposals for alignment to strategic objectives, deliverability, resourcing, governance and management process.
• Reviewing and supervising the claims criteria before claim submission.
• Handling all the aspect of Insurance like renewing contracts with the insurance company, sending the claims to the insurance company and following up for the payments
• Handling customer queries and grievances regarding their insurance policies and investigate their complaints and take necessary steps to promptly resolve the matter
• Developing and deploying a training program on new and old insurance policies from time to time for the hospital front office and back office staff keeping them updated
• Liaise with New Insurance Companies/TPA’s/Corporate for Contract/Addendum including all legal points and discusses the discounts to be applied on the covered services
• Advise and update the Hospital Management in relation to Insurance matters.
• Resolve the disputed issues with insurance Companies.
• Liaised with insurance companies to reduce rejections
• Coordinate with different parties, such as, ministry of health, DHA/ HAAD, contractors etc, to ensure projects are implemented on time. • Developing and implementing, appropriate office systems and procedures as required to efficiently operationalize the clinic.
• Liaising and maintain governmental relationship for investment support and licensing.
• Encourage and coordinate team members’ exploratory analyses on databases to establish relations and/or correlations to potentially exploit to enhance business performance
• Work with senior managers across departments throughout the project

• Managing and accountable for overall insurance aspects regarding revenue cycle, claims, network, approvals, rejection, receivables, billing, coding and timely submitting the claims both submission and re-submission.
• Responsible to develop, plan, organize and implement current and future strategies to process payments, improve cash flow and manage the overall company’s receivables.
• Implementing new innovative business strategies and provide clinical guidelines especially in coding CPT procedures and ICD 10 diagnosis as well as provide solution for the entire operational aspects for increasing the profit of the company.
• Supervise all the approvals and claims, ensures that proper justification and documentation are done before submission.
• Trains, guides and ensures that the receptions are checking the eligibility and collects accurate copayment from the patient. Manages, mentors, guides and motivate the team to achieve and exceeds daily target.
• Negotiates for the agreed tariff and provides inclusion with insurance companies.
• Reduce the rejection rate and ensures that proper justification is given.
• Build and establish excellent relationship with insurance companies especially from network, claims, finance and approval department and meets them for better relationship
• Handles complex patients’ complaints and issues by explaining the insurance guidelines.
• Compiles and prepares various status reports for management

• Manages the Insurance, Cash Payments, CME events, reception, doctors and nurses.
• Successful execution of all operational aspects related to Insurance including billing, medical Coding and approvals for submission and resubmission.
• Uplifts the profit of the company by reducing the rejection and provide patient satisfaction.
• Ensures that contracts are up to date for HAAD and Insurance SPC contracts
• Establishes clearly defined department and individual goals and objectives and communicates these to associates through department meetings and performance planning.
• Responds to patient’s inquiries and complaints regarding approval coverage
• Provide critical analytic and negotiation support with respect to payer reimbursement contracts and tariff finalization, collaborate with and guide department leadership to analyze billing and revenue integrity procedures
• Serve as an active leader in the functions of the revenue cycle operational departments.
• Provides all relevant documents to the Insurance Companies during Audits to emphasize that the Facility is abiding all the Insurance norms and rules.
• Responsible for auditing, validating and monitoring activities of Insurance department
• Standardization of processes and workflows for efficient and optimized delivery of service that meets the patient expectations in cost effective manner.
• Develop and manage the KPI’s and dashboards for increasing patient satisfaction
• Continue to drive the business to a profitable, high growth business with resilient processes oriented to achieving customer and business objectives.
• Handles the CME course and workshop accredited by Health Authority Abu Dhabi (HAAD) conducted by British Academy for Implant and Restorative Dentistry.

• In Charge for coding and auditing E & M (evaluation and management), laboratory, radiology, and procedures with corresponding ICD 9 diagnosis.
• Minimize the rejections from 20 percent to less than 5 percent rejection
• In command for approving inside tests and send outs which are covered and not covered by the insurance company.
• Analyze patient complaints and queries and adopt effective solution to resolve the problem.
• Liable for all the queries of our doctors ( Gastroenterologist, obstetrics / gynaecologist, internal medicine, dentist, urologist, dermatologist, venereologist, paediatrician, endocrinologist, and general practitioner)
• Online processing of medical claims and submissions using EMR (electronic medical record), MEDIPLUS HMS (hospital management system, CMR (clinical medical record) LABCARE and GREENRAIN.
• Determines policy coverage, and where necessary, investigates, evaluates, negotiates and equitable settles all assigned claims in accordance with insurance guidelines.
• In control for all the pre approvals, claim forms and reimbursement forms to be issued to the insurance companies and follow up on our request
• Accountable for the resubmissions and provide excellent justifications for all the tests that have been rejected.
• Ensures that all protocols complies with the HAAD guidelines, insurance guidelines and medical guidelines
• Negotiating with the insurance companies to have an excellent multiplying factor

• In Charge for coding and auditing E & M (evaluation and management), laboratory, radiology, and procedures with corresponding ICD 9 diagnosis.
• Minimize the rejections from 20 percent to less than 5 percent rejection
• In command for approving inside tests and send outs which are covered and not covered by the insurance company.
• Analyze patient complaints and queries and adopt effective solution to resolve the problem.
• Liable for all the queries of our doctors ( Gastroenterologist, obstetrics / gynaecologist, internal medicine, dentist, urologist, dermatologist, venereologist, paediatrician, endocrinologist, and general practitioner)
• Online processing of medical claims and submissions using EMR (electronic medical record), MEDIPLUS HMS (hospital management system, CMR (clinical medical record) LABCARE and GREENRAIN.
• Determines policy coverage, and where necessary, investigates, evaluates, negotiates and equitable settles all assigned claims in accordance with insurance guidelines.
• In control for all the pre approvals, claim forms and reimbursement forms to be issued to the insurance companies and follow up on our request
• Accountable for the resubmissions and provide excellent justifications for all the tests that have been rejected.
• Ensures that all protocols complies with the HAAD guidelines, insurance guidelines and medical guidelines
• Negotiating with the insurance companies to have an excellent multiplying factor

• Coordinating and Contacting Insurance companies regarding eligibility, payments, approvals, reconciliation and other requirements of their members.
• In charge in Medical Coding of ICD-9 AND CPT codes
• Online processing medical insurance claims in a timely manner using CLINIC PRO system.
• Prepares insurance forms, pre approvals, reimbursement forms and associated correspondences.
• Ensures correct billing and proper collection of the deductible and co-insurance from the patient
• Prepares the patients claim form and bills to be submitted to the respective Insurance Companies for payment.
• Entertains patient’s queries and reconciling with insurance companies regarding unpaid balances.
• Responsible for checking the claims completeness, for compliance with the CPT procedures and to ensure that the costs are in line with the ICD-9 diagnosis
• Verifies new patients insurances and re-verifies that of patients coming back on service.
• Gives quotations to the insurance companies by negotiating to them best multiplying factor that would be agreed by both parties.

• Process claims & invoices according to CPT4, ICD-9, and denial codes & specification (Consultation, Laboratory, Radiology, Dental Procedures Surgical and Non- Surgical, for both Inpatient and Outpatient)
• Analyze, computes and rejects claim to eliminates fraud and claim abuse accurately to our providers
• Provides high standards of professional conduct for claims services.
• Analyzed data using MEDNEXT Oracle System.
• Audits claims & invoices using CURT Auditing System.
• Teach and assists new recruit to process a claim, & techniques on improving quantity and quality.
• Makes a Hotkey Program especially design to make the work easier.
• Responsible for handling claims in accordance with prescribed authority and best claims practices.
• Utilized claims tools to analyze and make accurate assessments.
• Acts as a team leader especially when supervisor is not around.

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