1. Gemma L. Espiritu Santo - De Guzman, RN
80 R.Magsaysay Ave. San Gabriel
Teresa, Rizal 1880
Mobile No.: (0905) 551-2518 /0905355-5174
Email Address : agcjdeguzman@yahoo.com; gemma1230@yahoo.com
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PROFILE:
• More than twenty (20) years of experience in healthcare industry, able to manage
various claims projects with concentration on KPI’s, extensive experience in
utilization review management, customer service relations and providers
contracting
• Excellent organization and management skills, high standard of professional
behavior, competent, strong team player, skills in hiring, training and termination
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EMPLOYMENT HISTORY:
NetCare Life and Health Insurance - Manager, Medical Referral Office
1507 North Tower Cathedral Heights Bldg. Complex January 1, 2014 – Present
St. Luke’s Medical Center
Quezon City
• Oversees the medical referral functions and activities of the Manila office
operations including managing the full–scale activities of the Medical Referral
Office staff.
• Directly communicates and monitors with department staff in Guam the
appropriate routing of NetCare members to the respective specialists or
participating providers.
• Strictly monitors daily hospital admissions and timely delivery of quality and
cost-effective healthcare. Responsible for reporting of inpatient stays, high
cost claims, trigger diagnosis claims, etc.-assessment and monitoring of
utilization for hospital/ER admissions, concurrent reviews, discharge planning
and retrospective reviews, compiling all Provider contracts and ensuring all

2. credentials are complete, verified and accurate including Wellness /ECU
programs.
• Coordinates and supervises the preparation of monthly statistical reports on
Hospital admissions, Ambulatory/Surgical, Consultations, Executive Check-
up/Wellness check up, direct admissions, etc by facility.
• Oversee the preparation of the monthly accounting disbursement report, petty
cash report, supply requisitions, etc.
• Reports to Guam Management all office activities, member activities,
providers and staff daily activities. Monitored office supplies, equipment
supplies, vendor contracts, etc.
• Directly communicates with Guam Head Office for business-related concerns
and issues. Ensures the proper handling of all member concerns and inquiries,
requests from other departments, provider inquiries and appeals.

3. Moylan’s Representative Office
(NetCare Life and Health) - Manager, Health Claims Department
Subsidiary of Moylan’s Insurance –Guam,USA December 1,2010 – December 2013
6th Floor Eurovilla Bldg. 4
853 Arnaiz Ave.(Pasay Rd.) Legaspi Village
Makati City
• Responsible for managing the Claims Department and all resultant claims
processing functions.
• Developed and implemented claims processing procedures and guidelines to
provide consistent, accurate claims processing (including medical, dental, vision,
coordination of benefits, medicare) and efficient service to the participating
providers.
• Established procedures for pended, held and suspended claims and assigned
appropriate staff to monitor, release and maintain this function. Supervise eight
(8) claims adjudicators. Assists in the proper use of ICD 9 codes, HCPCS , CPT ,
Red Book(Pharmacy’s Reference Manual), Correct coder edits manual and sound
claims adjudication.
• Developed a working environment in which claims personnel are motivated to
perform to full potential increasing the over-all level of expertise and proficiency
of the claims adjudicators.
• Ensured timely and professional processing of claims and made sure that
necessary claims auditing procedures are developed and implemented.
• Established, monitored and reported on production and quality assurance goals for
Claims Department.
• Prepared month-end Key Performance Indicators (KPI) reports.
• Conducted claims staff performance reviews with the subordinates in accordance
with company established policies.
NetCare Life and Health Insurance - Manager, Medical Referral Office
1507 North Tower Cathedral Heights Bldg. Complex August 2008 to November 2010
St. Luke’s Medical Center
Quezon City
• Oversaw the medical referral functions and activities of the Manila office
operations including managing the full–scale activities of the Medical Referral
Service Coordinators and Medical Referral Associate.
• Directly communicated and monitored with department staff in Guam the
appropriate routing of NetCare members to the respective specialists or
participating providers.
• Strictly monitored daily hospital admissions and timely delivery of quality and
cost-effective healthcare. Responsible for reporting of inpatient stays, high
cost claims, trigger diagnosis claims, etc.-assessment and monitoring of

4. utilization for hospital/ER admissions, concurrent reviews, discharge planning
and retrospective reviews, compiling all Provider contracts and ensuring all
credentials are complete, verified and accurate including Wellness /ECU
programs.
• Coordinated and supervised the preparation of monthly statistical reports on
Hospital admissions, Ambulatory/Surgical, Consultations, Executive Check-
up/Wellness check up, direct admissions, etc by facility.
• Oversaw the preparation of the monthly accounting disbursement report, petty
cash report, supply requisitions, etc.
• Reported to Guam Management all office activities, member activities,
providers and staff daily activities. Monitored office supplies, equipment
supplies, vendor contracts, etc.
• Directly communicated with Guam Head Office for business-related concerns
and issues. Ensured the proper handling of all member concerns and inquiries,
requests from other departments, provider inquiries and appeals.
Moylan’s Representative Office
(NetCare Life and Health) - Health Claims Manager
Manila Office of NetCare/Moylan’s Insurance August 1,2005 to August 2008
(Guam, USA)
6th
Floor Eurovilla Bldg. 4
853 Arnaiz Ave.(Pasay Rd.) Legaspi Village
Makati City
• Responsible for managing the Claims Department and all resultant claims
processing functions.
• Developed and implemented claims processing procedures and guidelines to
provide consistent, accurate claims processing (including medical, dental, vision,
coordination of benefits, medicare) and efficient service.
• Established procedures for pended, held and suspended claims and assigned
appropriate staff to monitor, release and maintain this function.
• Supervised and trained the eight (8) claims adjudicators. Assisted in the proper
use of ICD 9 codes, HCPCS, CPT , Red Book(Pharmacy’s Reference Manual)
and sound claims adjudication.
• Developed a working environment in which claims personnel are motivated to
perform to full potential increasing the over-all level of expertise and proficiency
of the claims adjudicators.
• Ensured timely and professional processing of claims and made sure that
necessary claims auditing procedures are developed and implemented.

5. • Established, monitored and reported on production and quality assurance goals for
Claims Department.
• Prepared month-end Key Performance Indicators (KPI) reports.
• Conducted claims staff performance reviews with the subordinates in accordance
with company established policies.
Federated States of Micronesia Health Insurance Plan -Utilization Review Officer
(Managed by FSM Pohnpei Office) Oct. 1, 2003 to July 31, 2005
Rm. 1012 North Tower, CHBC
St. Luke’s Medical Center
Quezon City
Duties and responsibilities – same as below
Isla Data Services Philippines,Inc. – Health Claims Supervisor
8000 J.P. Rizal cor.Burgos St. Sept.16, 2002 to Sept.15, 2003
Makati Ave., Makati City
• Exercised direct supervision over six (6) claims processors.
• Reviewed the claims processed by the processors if they adjudicate the
claims correctly based on the members plan including proper use of health care
coding system. Advised the processors with sound judgment on the claims and makes
necessary changes to the processed claims.
• Assisted the claims processors in all their inquiries on proper claims
adjudication including the proper use of AS 400 system, ICD 9 codes, CPT codes,
HCPCS, medical terminologies, non-covered/covered charges and others related to
proper documentation. Claims received are from different countries such as
Hongkong, China, Japan, Thailand, Europe, Singapore and United States.
• Developed and implemented new strategies to increase production and
improve the claims adjudication.
• Conducted the claims staff performance appraisal.

6. Palau Medical Referral Office - Utilization Review Coordinator
1702 16th
Ave., New Manila St. March 2003 to March 2004
Quezon City (Part Time Job)
• Monitored hospital and clinic utilization of all patients referred from the
Government of Palau Medical Referral Committee (Palau Island Office) to
Manila for medical care.
• Reviewed medical records of patients to determine appropriateness of the level of
care and length of stay for utilization purposes.
• Reviewed all bills for payment and checked the accuracy and appropriateness of
the claims.
• Submitted all bills that are not disputed to the Medical Referral Coordinator for
payment.
• Prepared monthly statistical reports and status reports on the medical expenses of
all patients.
• Reported to the Medical Referral Coordinator all bills that are in dispute and
attempted to resolve the disputes with medical care providers. If not resolved, the
dispute will be reported to the Medical Referral Coordinator for further action.
• Coordinated with medical care providers regarding the status of member’s
condition and length of stay in the hospital for utilization management purposes.
• Performed additional duties as maybe required in the course and scope of
executing the function of the Utilization Review Coordinator and the fulfillment
of duties to the Government of Palau Medical Referral Committee.
Federated States of Micronesia Health Insurance Plan -Utilization Review Officer
Managed by FSM Pohnpei Office ) March 2000 to Sept. 2002
Rm. 1012 North Tower ,CHBC
St. Luke’s Medical Center
Quezon City
• Processed the professional fees based on the Philippine College of Surgeon’s
Relative Unit Value (RUV) Manual with complete information: final diagnosis,
date of service, description of procedures done, treatment and surgical procedures
done to the patients as well as application of correct CPT codes and HCPCS .
• Prepared correspondences on the complaints of the doctors regarding the amount
of professional fees they have received for medical services and/or surgical cases.
• Prepared concurrent review for in patient cases - reviewed medical records of the
patients confined in the affiliated hospitals and gathered data to determine the
appropriateness of level of care, intensity of service, length of stay for utilization
management purposes.

7. • Coordinated with the medical providers on the length of stay, treatment and
management of the patients admitted at the hospitals for utilization purposes. In
regard to the long standing patients, requested the attending physician to provide
medical report to justify the extension of stay in the hospital of the patients.
• Reviewed the medical benefits of the patients referred by Federated States of
Micronesia Health Insurance Plan main office based on their choice of plan for
proper collection of patient’s share upon their discharge. Explained to the patients
about the non-covered charges and personal charges they need to pay upfront
upon discharge.
• Prepared the medical updates of the patients confined at the hospitals which
include the results of all laboratory/diagnostic procedures done and surgical
procedures done. Reported to the Chief Utilization Review Officer weekly the
problems, medical treatment and management of the admitted patients.
• Prepared imprest fund disbursement reports and submitted to the Chief Financial
Officer for the replenishment of funds.
• Prepared all the billings for payment, checks for the providers (hospitals, doctors
and medical suppliers). Responsible of adjudicating and payment of legitimate
medical bills incurred from the accredited hospitals.
• Coordinated directly with St. Luke’s Medical Center Medical Director and
Accounts and Billings Manager for any problems encountered by the FSMHIP
patients particularly the services rendered by the hospital staff and any
discrepancy on the hospital claims.
• Prepared monthly utilization report with corresponding comments and analysis on
the medical expenses incurred by the patients and its implications to the financial
status of the program ( health insurance plan) and submitted the reports to the
Secretary of Finance and Administration in Federated States of Micronesia.
• Assisted the patients who come in the office and referred them to the specialists
accordingly.
Guam Memorial Health Plan –Manila Office - Utilization Reviewer/Coordinator
RM.1412 Cathedral Heights Bldg. Complex September 1994 to February 2000
St. Luke’s Medical Center
Quezon City
• Monitored the hospital utilization of the patients coming in the hospital and at
the clinics in Manila. Reviewed the medical benefits of the Guam Memorial Health
Plan (GMHP) patients who are admitted at St. Luke’s Medical Center, reviewed the
different benefit plans of GMHP for the limitations of benefit coverage of patients
being referred to Manila for evaluation and management.
• Coordinated with Guam office if there are referrals from Micronesia or Guam.
Coordinated with the medical coordinator for the admitting orders, room reservation
and ambulance conduction if necessary.

8. • Explained to the patients if there are any non-covered charges based on their
choice of plan so that they can pay their share upfront upon discharge. Explained the
benefits coverage as stipulated in the member’s plan.
• Visited the confined members in the hospital and checked the status of the
patient’s condition while admitted and prepared medical updates of the admitted
patients and submitted the reports to the Guam Office weekly.
• Concurrent review- reviewed medical records of the patients to determine the
appropriateness of level of care, intensity of service and length of stay for the
utilization purposes.
• Processed the professional fees based on the Philippine College of Surgeon’s
RUV (Relative Unit Value) manual.
• Prepared reports on the hospital bills, professional fees and other expenses of
the office/clinic for payment purposes.
• Reported directly to GMHP Chief Financial Officer for the payment of the
legitimate medical expenses incurred by the members from the hospital and all other
office/clinic expenses.
• Adjudicated claims based on the benefits of the members using AS 400
system with correct ICD 9 Codes and CPT codes (Current Procedural Terminology)
• Exercised direct supervision over the clinic secretary and the medical liaison
officer.
• In absence of the Office Manager, undertook her duties and responsibilities in
the office.
Plastic Container Packaging Corporation - Company Nurse
Madison St. Mandaluyong, City January 1994 – September 1994
• Monitored the workers in their working areas daily for any minor accidents,
illnesses and other complaints.
• Performed nursing functions in cases of minor illnesses and accidents, if
encountered complicated cases referred the employees to the company physician
or the nearest hospital for further evaluation and treatment.
• Responsible in the Social Security System (SSS) sickness and maternity benefits
of the employees.
• Prepared monthly report on the accidents and different diseases experienced by
the employees during working hours.
• Directly reported to the Vice-President.

9. Fortune Care,Inc.
Dela Rosa St. cor. Amorsolo St. – Clinic/Company Nurse
Makati City June 1990 – December 1992
• Referred patients to the specialists (Cardiology, Gastroenterology, Pedia,
Internal Medicine, General Surgery, Ophthalmology, Orthopedic Surgery) depends
upon the complaints/problems of the patients.
• Assisted the physicians in the Operating Room when minor operations done
(e.g. excision of cyst, cleansing of wound, removal of foreign body, change of
dressing, removal of staples).
• Accompanied the physician in the company’s visit monthly for the annual
physical examination and health instructions as preventive treatment.
• Performed the nursing functions such as administering vaccinations, skin
testing when there are cases of special radiological procedures, performed ECG as
requested, provided health instructions about the prevention and minor treatment of
the different diseases necessarily.
• Assessed the patients who come in the clinic: get the personal data, history of
present illness, complaints and other necessary medical information about the patient.
• Provided emergency treatment to minor cases such as bleeding wounds,
dizziness, hypertension and other diseases which need urgent nursing functions.
EDUCATIONAL BACKGROUND
College - Bachelor of Science in Nursing
1986-1990
Far Eastern University
Morayta, Manila
Secondary - 1982-1986 (Top Twenty Class)
Rizal State College

10. Morong, Rizal
Primary - 1976-1982
Consistent First Honors (1976-1981)
Valedictorian (1982)
TRAININGS/SEMINARS ATTENDED
Jose Reyes Memorial Hospital - January 1993 to June 1993
Sta. Cruz ,Manila (Volunteer staff)
Healthkard Hospital - July 1993 to December 1993
Herrera St. Makati City (Volunteer Staff)
** Seminars attended available upon request.
EXAMINATIONS PASSED
National College Entrance Examination - 1986
Nurse’s Licensure Examination - 1990
SPECIAL /OTHER SKILLS
Certified Medical Billing Specialist
Computer skills – Microsoft office, Powerpoint, Acrobat