Engeline Gapulao
Summary
Dynamic healthcare professional with extensive experience in provider management and claims adjudication at Doctor Anywhere Operations. Proven track record in optimizing billing practices and enhancing cost-effective care delivery. Skilled in case management and proficient in LOG assessment, with strong negotiation abilities and a commitment to improving operational efficiency.
Overview
22
22
years of professional experience
1
1
Certification
Work History
Senior Medical Case Assessor
Doctor Anywhere Operations
01.2025 - Current
- Assess inpatient and outpatient medical cases for pre-authorization issuance, ensuring alignment with policy terms and clinical appropriateness.
- Review treatment plans, diagnoses, and supporting documentation to determine coverage eligibility and medical necessity.
- Liaise with hospitals, and doctors to clarify medical information and coordinate approvals.
- Negotiate rates and pricing with providers to ensure cost-effective care delivery for insured clients.
- Provide guidance to junior assessors on complex cases, policy interpretation, and clinical review standards.
Manager, Provider Management
Doctor Anywhere Operations
11.2021 - 01.2025
- Analyzed clinic bill sizes and collaborate with panel clinics with high bill sizes to optimize billing practices and reduce unnecessary costs.
- Provided training and support to new and existing panel GPs, Specialists and other allied health professionals regarding the processes and use of portals.
- Assisted with the resolution of escalated provider concerns and disputes.
- Collaborated with cross-functional teams, including LOG, Claims, Customer Service, Finance and Legal departments, to streamline Managed a team, track, and monitor team response times to queries, ensuring all queries are answered accurately and within TAT.
Associate Manager, Provider Management
Alliance Medinet
04.2020 - 11.2021
- Worked closely with panel providers to negotiate and establish cost-effective pricing for Health Screening, Dental, Web talks and Pre-employment and work permit services based on client’s needs.
- Regularly reviewed costs and implemented strategies to control expenditures.
- Collaborated with regional partners to expand and enhanced network of healthcare providers in other countries such as Hongkong, Indonesia, Thailand, and Malaysia.
- Developed and implemented training sessions for new panel providers to ensure they are well-versed in protocols, compliance standards, and service expectations.
- Provided regular reports to senior management on the effectiveness of regional operations and panel provider performance, highlighting areas for improvement and growth opportunities.
Assistant Manager, Provider Management
Integrated Health Plans
07.2019 - 04.2020
- Served as a point of contact for Government hospital partners, addressing queries and providing guidance on the proper procedures.
- Conducted training sessions for hospital staff, providing them with the knowledge and tools to streamline processes.
- Addressed queries from medical providers regarding benefits coverage and claims payments, providing clear and timely information.
- Worked with internal teams and panel providers to resolve any disputes or concerns.
Senior Claims Executive, Claims and LOG
Raffles Health Insurance, Singapore
04.2017 - 07.2019
- Managed end-to end process of inpatient claims processing and LOG issuance for key clients, ensuring all claims were processed accurately and efficiently.
- Regularly checked team backlogs, identifying any bottlenecks in the workflow and actively worked to resolve any delays.
- Assisted in the approval of outpatient claims processed by junior claims processors, reviewing their work to ensure accuracy and compliance with policies.
- Conducted trainings and developed training materials to ensure new hires were well-prepared to handle claims processing.
Team Lead, Clinic Relations
Integrated Health Plans, Singapore
03.2011 - 03.2017
- Spearheaded efforts to recruit new clinics into the managed healthcare network, expanding the range of services provided to corporate clients.
- Conducted training sessions for new and existing panel clinics on using the portal or claims submissions. Ensured that clinics were proficient in using the system to reduce errors and improve claims processing efficiency.
- Collaborated closely with medical audit team in identifying any discrepancies and implementing corrective actions to ensure compliance with the protocols.
- Established clear performance metrics for the team in tracking progress to set targets effectively.
Team Lead, Benefits and Claims
APAC Customer Service (Blue Cross of California Insurance Account), Philippines
02.2006 - 10.2010
- Led and mentored a team of 15 agents handling provider calls related to Blue Cross of California insurance benefits, eligibility, and claims status.
- Provided support for complex claims issues and acted as an escalation point for difficult provider queries.
- Assisted with the training and development of new team members on claims processes, software systems and timely information.
Provider Care Representative, Benefits and Claims
Teletech Customer Care Management Blue Shield of California Insurance Account), Philippines
07.2003 - 01.2006
- Utilized multiple systems for claims research. contract interpretation, fee schedule, and provider network status.
- Processed claims and provided back-office support, ensuring all claims were handled in compliance with company policies and guidelines.
- Coordinated with different channels and departments to resolve complex claims issues, ensuring timely and accurate resolutions.
Education
Bachelor of Science - Physical Therapy
St Jude College
Philippines09-2002
Skills
- Healthcare provider management
- Claims adjudication
- Case management
- Proficient in LOG assessment
- Claims resolution experience
Certification
- Health Insurance Certificate (Singapore College of Insurance)
- HIPAA Compliance Trained (US)
- Team Lead Certification (Philippines)
- Medical Coding Certification (Udemy)
Languages
English
Advanced (C1)
Timeline
Senior Medical Case Assessor
Doctor Anywhere Operations
01.2025 - Current
Manager, Provider Management
Doctor Anywhere Operations
11.2021 - 01.2025
Associate Manager, Provider Management
Alliance Medinet
04.2020 - 11.2021
Assistant Manager, Provider Management
Integrated Health Plans
07.2019 - 04.2020
Senior Claims Executive, Claims and LOG
Raffles Health Insurance, Singapore
04.2017 - 07.2019
Team Lead, Clinic Relations
Integrated Health Plans, Singapore
03.2011 - 03.2017
Team Lead, Benefits and Claims
APAC Customer Service (Blue Cross of California Insurance Account), Philippines
02.2006 - 10.2010
Provider Care Representative, Benefits and Claims
Teletech Customer Care Management Blue Shield of California Insurance Account), Philippines
07.2003 - 01.2006
Bachelor of Science - Physical Therapy
St Jude College
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