JAY-AR B. GUIYAB, RN, CPC

(u517) Ah Dullah Bldg. Al Barsha 1 Dubai UAE

Mobile No.: +971502225046

Email address: [email protected]

OBJETIVE_______________________________________________________________________

To gain a competent and productive career in the field of Medical Insurance Claims Processor / Insurance Coordinator / Medical Coder where my knowledge and skills are further enhanced by contributing to an institution that can offer development and growth.

HIGHLIGHTS OF QUALIFICATIONS_______________________________________________

Interface well with all levels of personnel to achieve efficient result, good command in English and Filipino languages and excellent microsoft office (powerpoint, word, outlook and excel) skills.

PERSONAL STRENGTH___________________________________________________________

Accurate, systematic, keen to details, with sense of urgency, high level of integrity, loyalty and commitment. Creative, result-oriented, with mature disposition and good interpersonal skills.

WORK EXPERIENCES____________________________________________________________

·         CLAIMS EXECUTIVE                                                                            May 2018 – Present

Wapmed TPA Services

Al Baker Building

Dubai Healthcare City, Dubai, UAE

Responsibilities

·         Handle Client, provide email, isues/complaints and follow up and provide solutions.

·         Assess and process all pre-approval requests.

·         Coordinate with provider for additional information if required to assess approvals.

·         Adjudicate both paper and e-claims.

·         Answer incoming calls related to pre-approvals, medical querries, and insurance policies.

·         Ensure all complaints encountered during any process are logged and resolved.

·         Manage resolution of problems in a timely manner.

·         Maintain daily log reports to assess performance.

·         MEDICAL CODING ANALYST                                                            May 2016 – February 2018

Quality and Risk Adjustment Operations

Optum Global Solutions – UnitedHealth Group

McKinley Hill, Taguig City Philippines

Responsibilities:

Audits records to ensure proper submission of services prior to billing on pre-determined selected charges
Supplies correct ICD-9-CM /ICD-10-CM diagnosis codes on all diagnoses provided
Supplies correct HCPCS code on all procedures and services performed
Supplies correct CPT code on all procedures and services performed
Attends seminars and in-services as required to remain current on coding issues
Audits medical records to ensure proper coding completed and to ensure compliance with federal and state regulatory bodies
Accurately follows coding guidelines and legal requirements to ensure compliance with federal and state regulatory bodies
Maintains compliance standards in accordance with the Compliance policies and the Code of Conduct. Reports compliance problems appropriately.
Determines the final diagnoses and procedures stated by the physician or other health care providers are valid and complete.
Quantitative analysis – Performs a comprehensive review for the record to assure the presence of all component parts such as: patient and record identification, signatures and dates where required, and all other necessary data in the presence of all reports which appear to be indicated by the nature of the treatment rendered.
Qualitative analysis – Evaluates the record for documentation consistency and adequacy. Ensures that the final diagnosis accurately reflects the care and treatment rendered. Reviews the records for compliance with established reimbursement and special screening criteria.
·         PHARMACY BENEFITS ANALYST                                         February 2014 – May 2016

Benefit Operations Management

Optum Global Solutions – UnitedHealth Group

McKinley Hill, Taguig City Philippines

Responsibilities:

Analyze benefit requests and secure all necessary  data to ensure appropriate implementation based on applied logic of  RxCLAIM (by SXC) pharmacy claim adjudication system.
Work with Client Management to implement new and maintain existing benefit plans and client pricing in the pharmacy  claim adjudication system.
Work with Clinical Pharmacy to implement formulary updates and clinical programs in the pharmacy claim adjudication system
Work with Pharmacy Network Management to implement pharmacy rate changes and network additions in the pharmacy  claim adjudication system
Develop client specific implementation plans and manage implementation processes in accordance with department protocol
Perform claim testing to ensure accurate claim adjudication
Maintain acceptable and appropriate quality levels and production turn around times
Research and respond to all claims processing inquiries from Client Management, Clinical, and other internal department.
·         PHARMACY BENEFITS ANALYST                             September 2012 – February 2014

Seven Seven Global Services Inc.

27th Floor, Orient Square Building

F. Ortigas Jr. Road Pasig City Philippines

Responsibilities:

Analyze benefit requests and secure all necessary  data to ensure appropriate implementation based on applied logic of  RxCLAIM (by SXC) pharmacy claim adjudication system.
Work with Client Management to implement new and maintain existing benefit plans and client pricing in the pharmacy  claim adjudication system.
Work with Clinical Pharmacy to implement formulary updates and clinical programs in the pharmacy claim adjudication system
Work with Pharmacy Network Management to implement pharmacy rate changes and network additions in the pharmacy  claim adjudication system
Develop client specific implementation plans and manage implementation processes in accordance with department protocol
Perform claim testing to ensure accurate claim adjudication
Maintain acceptable and appropriate quality levels and production turn around times
Research and respond to all claims processing inquiries from Client Management, Clinical, and other internal department.
LICENSES/CERTFICATES_________________________________________________________

·         Certified Professional Coder                                                                   June 2015 – Present

ICD-10 Proficient

American Academy of Professional Coders

Salt Lake City Utah

Membership ID: 01375535

·         Nurse Licensure                                                                                   March 2011 –  Present

Professional Regulation Commission

Manila City Philippines

License No.:  0672149

EDUCATION_____________________________________________________________________

·         Bachelor of Science in Nursing                                                      June 2007 – October 2010

Our Lady of Fatima University

Valenzuela City Philippines

TRAININGS/SEMINARS ATTENDED________________________________________________

·         Time Management                                                                                                     August 12, 2016

Optum Global Solutions – UnitedHealth Group

McKinley Hills, Taguig City Philippines

·         Fish Tales                                                                                                         July 22, 2016

Optum Global Solutions – UnitedHealth Group

McKinley Hills, Taguig City Philippines

·         Problem Solving Skills                                                                                       July 15, 2016

Optum Global Solutions – UnitedHealth Group

McKinley Hills, Taguig City Philippines

·         Situational Self Leadership                                                                               April 7, 2016

Optum Global Solutions – UnitedHealth Group

SMX Convention Center SM Aura Premier

Bonifacio Global City, Taguig City Philippines

·         Complaints to Compliments                                                                              April 5, 2016

Optum Global Solutions – UnitedHealth Group

McKinley Hills, Taguig City Philippines

·         Leadership Development Program                                                  May 2015 – August 2015

Benefit Operations Management

Optum Global Solutions – UnitedHealth Group

McKinley Hills, Taguig City Philippines

·         CPC Training                                                                               January 2015 – June 2015

Teledevelopment Services Inc.

ADB Avenue Ortigas Center, Pasig City Philippines

·         Lean Training                                                                                                        May 2015

Optum Global Solutions – UnitedHealth Group

McKinley Hills, Taguig City Philippines

·         Business Etiquette                                                                                               May 2015

Optum Global Solutions – UnitedHealth Group

McKinley Hills, Taguig City Philippines

·         Messaging & Presentation Skills                                                                        May 2015

Optum Global Solutions – UnitedHealth Group

McKinley Hills, Taguig City Philippines

·         International Education Conference: NURSE Forum                                        June 2014

OptumHealth Education

Sofitel Philippine Plaza

Roxas Boulevard, Pasay City Philippines

·         Business Writing Skills                                                                                       May 2014

Optum Global Solutions – UnitedHealth Group

McKinley Hills, Taguig City Philippines

·         Six Sigma White Belt Training                                                                      September 2012

United Health Group

McKinley Hill Taguig City Philippines

PERSONAL INFORMATION_______________________________________________________

Place of Birth         : Cabagan, Isabela

Date of Birth          : January 10, 1987

Citizenship             : Filipino

Civil Status                        : Single

Visa Type              : Residence Visa

CHARACTER REFERENCES_______________________________________________________

·         Julie Joaquin

Team Leader, Client Services

Wapmed TPA Services

+971509451564

·         Antonino Coquia

Senior Claims Executive

Wapmed TPA Services

+971555083169