Hermie Sabejon Jr.
Houston,United States
Summary
High-performing professional with integrity and leadership skills. Applies knowledge and abilities to positively impact organization. Flexible in different situations and dynamic conditions. Works great under extreme stress and deadlines. Analytical professional with technical knowledge and critical thinking skills to thrive in data-driven environments. Tackles challenges with positivity and drive to overcome. Works great alone or with others and consistently exceeds expectations.
Overview
14
14
years of professional experience
1
1
Certification
Work History
Medical Adjudication Officer
International Services - National Health Insurance Company - Daman
Abu Dhabi, United Arab Emirates
06.2013 - 10.2020
- Process and adjudicate local and international reimbursement claims (Inpatient/Outpatient) in accordance with the adjudication rules and standards as per policy terms
- Reports and audits the claims if assigned by the team lead/supervisor
- Evaluate medical necessity and consistency of diagnosis, procedure and drug codes and descriptions stated on the claims according to accepted medical coding rules and guidelines
- Cites, reports fraud and abuse and/or suspicious claims and investigates further for the same
- Ensures accurate application of contractual prices and discounts (if available)
- Understands and works with mandated code sets (ICD-9 and ICD-10, CPT codes, HCPCS and drug codes)
- Adjudicates for provision of deductibles, co-pays, co-insurance maximums and provider settlements
- Effectively liaise with and attend to provider, member or other departments' queries and appeals (answering phone calls, replying to emails, etc.) and required information in a timely and professional manner
- Supports in training of new joiners through shadow training.
Nursing Assistant
LLH Hospital
Mussafah, Abu Dhabi
03.2009 - 05.2013
- Work with policies of Lifeline including mission, vision, and core values
- Assists the Doctor in all minor procedures and all document work
- Giving priority for the appointment patients & sick patients
- Assists the doctor in reinforcing the health teachings to patients for optimum health growth and keeps records for future follow up consultations
- Guides the patients to Laboratory, Radiology, and Pharmacy & Pre anesthesia evaluation if advised
- Sending requests for approval to the Insurance department according to the insurance rules
- Inform the patients regarding the status of approval and if approved give appointment to do concerned procedures after informing the Doctors
- Participates in educational and quality improvement services
- Ensure patient safety and reports any incidents or unsafe practice to the Charge Nurse
- Initiates emergency codes as appropriate
- Participate in Quality programs when needed.
Operating Room Head Nurse - Staff Nurse
Kabacan Polymedic Cooperative Hospital
Kabacan North Cotabato, Philippines
03.2007 - 10.2008
- Assists surgeons in performing Major and Minor surgical operations such as Exploratory Laparotomy, appendectomy and Caesarean Section
- Plans, gives and evaluates nursing care
- Carries out doctor's legal orders
- Prepares patient for, and assist physicians, surgeons with, diagnostic, therapeutic and surgical procedures
- Assists the doctors during rounds and provides necessary information regarding the progress of the patients at the same time reinforcing health teachings to promote optimum health growth.
Education
Bachelor of Science in Nursing -
Notre Dame University
Cotabato City, Philippines03-2006
Skills
- Basic analytical
- Execution
- Problem solving
- Decision-making
- Strong leadership skills
- Make sound decisions quickly
- Work with limited supervision
- Drive to ensuring results and quality of work
- Coverage Determination
- Advance skills and knowledge in Microsoft Office products (Excel, Word, PowerPoint)
- Claims review
- Medical terminology knowledge
- Insurance Claim Forms Review
- Task Prioritization
- Claims Processing
- Adaptability and Flexibility
Certification
- Professional Regular Commission (Board of Nursing), 0432576, Davao City, Philippines
- BLS Certification (American Red Cross), 01JQV4G, 06/24/24
References
References available upon request.
Timeline
Medical Adjudication Officer
International Services - National Health Insurance Company - Daman
06.2013 - 10.2020
Nursing Assistant
LLH Hospital
03.2009 - 05.2013
Operating Room Head Nurse - Staff Nurse
Kabacan Polymedic Cooperative Hospital
03.2007 - 10.2008
Bachelor of Science in Nursing -
Notre Dame University
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