Medical Insurance

DIXIE P. DELA CRUZ

Ellesmere Road, Toronto, Ontario, M1P 2X6

Mobile Phone: 416-***-****

E-mail: aboygh@r.postjobfree.com

SUMMARY OF QUALIFICATIONSOver 6 years of experience in group health/medical benefits administrationStrong background in medical claims management, utilization review and healthcare provider relationsChartered Insurance Institute Certification (Insurance Practice and Healthcare Insurance)Graduate of B.S. Medical Technology and Doctor of MedicineExcellent organizational, interpersonal and communication skills

SKILLS AND EXPERIENCE

Medical Claims, Utilization and Case ManagementEvaluated claims to determine eligibility as per member’s benefit package, coding and billing accuracy, and compliance with company policies and procedures.Conducted medical necessity reviews of inpatient admissions, diagnostic testing and ambulatory services utilizing established guidelines and clinical judgment.Managed enquiries relating to authorizations, payments, denials, appeals and

coordination of benefits, and interfaced with customers by telephone, correspondence and/or in person to answer questions and resolve process issues.Monitored complex inpatient care provided to members including discharge plans, available covered services, alternative levels of eligible care or transfer coordination to support continuity of treatment, improved quality outcomes and decreased costs. Served as a resource both to department staff and those outside the department

for medical information and consultation on issues relating to clinical services, and case/utilization management activities.

Healthcare Provider RelationsInterfaced with medical providers with regard to tariff agreements, discounts, administrative guidelines, benefits and utilization management policies and procedures.Communication with the hospital administration and attending physician to ensure adherence on the covered medical services.Assisted providers with questions and concerns regarding claims

related issues, credentialing and inclusion into the company’s preferred network.

Management/TrainingEstablishment and implementation of evidence based medical guidelines and administrative proceduresManaged claims processors and customer support representativesConducted training on medical insurance policies, procedures and IT applications

EMPLOYMENT HISTORY

Staff Physician Reviewer 3/2012 – 6/2012

MediCall, Makati, Philippines

Claims Specialist (Medical Services) 2009 - 2011

Emirates Group, Dubai, United Arab Emirates

Senior Medical Insurance Officer 2008 - 2009

Al Ahli Hospital, Doha, State of Qatar

Assistant Manager/Medical Resource Specialist 4/2007 – 12/2007

Maxicare Healthcare Incorporation, Makati, Philippines

Customer Support Supervisor/Medical Officer 2004 - 2006

Globemed Saudi, Riyadh, Kingdom of Saudi Arabia

Preapproval Doctor 2003 - 2004

Arabian Brokers for Insurance and Reinsurance, Riyadh, Kingdom of Saudi Arabia

EDUCATION

Chartered Insurance Institute Certification 2004

(Insurance Practice and Healthcare Insurance)

Chartered Insurance Institute, London (through distance correspondence)

Doctor of Medicine (M.D.), 1996 – 2000

Ranked 15th in a class of 183 students

University of the City of Manila, Philippines

B. S. Medical Technology, Cum Laude 1991 – 1995

Far Eastern University, Manila, Philippines

REFERENCES

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