Natalio R Artiles

• Managed and supervised a team of case managers, ensuring efficient handling of international health insurance claims, pre-authorizations, and medical necessity reviews.
• Conducted in-depth evaluations of complex medical cases, coordinating with healthcare providers, policyholders, and insurance underwriters to determine appropriate coverage and medical necessity.
• Facilitated discharge planning, medical repatriation, and coordination of care for international patients requiring specialized treatment.
• Reviewed and audited medical records, ensuring accuracy in claim processing and compliance with insurance policies.
• Collaborated with international healthcare providers, negotiating service rates and ensuring cost-effective healthcare delivery for policyholders.
• Provided expert guidance on international healthcare systems, policy interpretation, and coverage limitations to clients and internal teams.
• Developed and implemented strategies to improve case management efficiency, optimizing workflows and enhancing customer satisfaction.
• Acted as a liaison between insurance carriers, healthcare providers, and policyholders to resolve escalated cases and disputes.
• Conducted staff training on best practices, industry regulations, and emerging trends in international health insurance case management.

• Claims Evaluation & Processing:Review and assess medical claims for accuracy, completeness, and compliance with policy guidelines.
  Determine claim eligibility based on policy terms, medical necessity, and applicable international healthcare regulations.
  Process claims efficiently while ensuring cost containment and preventing fraudulent activity.
  
• Medical Necessity & Coverage Determination:Analyze medical documentation, invoices, and supporting records to verify the necessity of treatments and procedures.
  Coordinate with medical teams, case managers, and underwriters for complex cases requiring clinical input.
  Ensure alignment with medical coding standards (ICD, CPT, DRG) and global insurance practices.
  
• Fraud Detection & Compliance:Identify potential fraud, abuse, or overutilization of medical services and escalate cases for further investigation.
  Adhere to international insurance regulations, including GDPR, HIPAA, and other compliance standards.
  Maintain strict confidentiality in handling sensitive patient and insurance data.
  
• Cost Containment & Provider Negotiations:Verify medical billing for appropriate charge rates, duplicate claims, and excessive charges.
  Work with contracted providers to ensure cost-effective healthcare delivery for policyholders.
  Assist in negotiating discounts with international healthcare providers when applicable.
  
• Claims Decision & Settlement:Approve, deny, or adjust claims based on policy terms and clinical guidelines.
  Communicate claim decisions clearly and professionally to policyholders, brokers, and healthcare providers.
  Ensure timely resolution of claims while maintaining high levels of accuracy and efficiency.
  
• Customer Service & Dispute Resolution:Address policyholder inquiries, disputes, and appeals regarding claim decisions.
  Collaborate with internal teams, including case management and legal departments, to resolve escalated claims.
  Provide clear explanations to clients regarding policy coverage, exclusions, and reimbursement processes.
  
• Data Analysis & Reporting:Maintain accurate records of claim adjudication decisions for internal audits and reporting.
  Analyze claim trends, provider billing patterns, and cost utilization to support risk management strategies.
  Contribute to process improvements and automation initiatives to enhance claim adjudication efficiency.
  

Medical Case Coordination:

• Assist policyholders in accessing appropriate medical services within the insurance network.
• Coordinate medical treatments, hospitalizations, and specialist referrals in different countries.
• Ensure timely medical authorizations and approvals for necessary treatments.

Pre-Authorizations & Medical Review:

• Evaluate medical requests for procedures, hospital stays, and specialized treatments.
• Determine medical necessity and align approvals with policy coverage guidelines.
• Collaborate with case managers and medical professionals for complex cases.

Medical Provider Liaison & Network Management:

• Communicate with international healthcare providers to arrange treatments and negotiate costs.
• Ensure policyholders receive care at accredited facilities while maintaining cost-effectiveness.
• Address provider inquiries regarding policyholder eligibility and coverage limitations.

Claims Support & Documentation Review:

• Assist in verifying medical claims and supporting documents for accuracy and compliance.
• Review medical reports, prescriptions, and treatment plans to ensure alignment with policy terms.
• Work with claims adjudicators to clarify clinical details and facilitate claims processing.

Emergency Assistance & Medical Evacuations:

• Coordinate urgent medical evacuations and repatriations when necessary.
• Work with air ambulance services and international hospitals to ensure seamless medical transfers.
• Provide real-time support in emergency cases requiring immediate intervention.

Regulatory Compliance & Risk Management:

• Ensure adherence to international insurance regulations and healthcare compliance standards.
• Identify and mitigate potential risks related to fraudulent claims or unnecessary treatments.
• Maintain confidentiality and security of medical records as per HIPAA/GDPR guidelines.

Curriculum Development & Instruction:

• Design and deliver structured lessons on medical billing, coding, and healthcare reimbursement methodologies.
• Provide in-depth instruction on ICD-10, CPT, HCPCS coding systems, and medical terminology.
• Utilize various teaching methods, including lectures, case studies, and hands-on coding exercises.

Training in Medical Billing & Insurance Procedures:

• Educate students on medical billing processes, claims submission, payment posting, and insurance verification.
• Explain healthcare reimbursement systems, including Medicare, Medicaid, and private insurance payers.
• Train students in handling denials, appeals, and compliance with insurance regulations.

Hands-On Coding Practice & Software Training:

• Provide practical coding exercises using real-world medical records.
• Train students in using electronic health record (EHR) and medical billing software.
• Ensure students develop proficiency in coding guidelines and claim adjudication.

Certification Preparation & Exam Readiness:

• Prepare students for industry certifications such as CPC, CCS, or CCA.
• Conduct mock exams, practice tests, and review sessions.
• Offer guidance on test-taking strategies and industry expectations.

Regulatory Compliance & Ethics Education:

• Educate students on HIPAA regulations, patient privacy laws, and ethical coding practices.
• Discuss compliance with medical coding standards and fraud prevention in billing.