MARIA CONCEPCION DAVALOS NOCHE
Unit 51 79/87 Boyce Road Maroubra Sydney,NSW
Summary
Seeking a challenging position thus acquiring more knowledge, enhancing my skills and develop a positive attitude in Health Care Services.
Overview
16
16
years of professional experience
1
1
Certification
Work History
Associate Preauthorization Medical and Life Claims
SUKOON INSURANCE
01.2023 - 07.2023
- Ensure timely review of ePAR cases and process asper prescribed guidelines and protocols.
- Responsible for issuing accurate pre-approvals to the providers and deliver excellent customer service.
- Review pre-approval request and adjudicate as per defined policy terms and conditions/clinical/regulatory guidelines.
- Answer calls from pharmacies, providers, and customers using exemplary customer service skills.
- Review clinical data matching it against specified medical terms and/or diagnosis/procedure codes and follow established procedure for authorizing preapproval request.
- Establish effective rapport with other employees and supervisor and maintain cooperative working relationship; actively support departmental activities.
Insurance Executive
MEDCARE HOSPITAL SHARJAH
01.2022 - 12.2022
- Evaluate the pre-approval request from medical necessity for the requested service according to the medical data provided and accurately code the service description stated on the prior authorization request .
- Respond to insurance /TPA queries and liaise with concerned department without delay.
- Responsible for receiving, evaluating and escalating opinion case and case management.
- Train front office, receptionist and nurses and keep them updated about insurance details.
- Performs any other jobs or duties assigned by HOD from time to time within the scope of job title.
- Be familiar with emergency and evacuation procedure.
- Responding to all calls from different department with regards to insurance.
- Prepares report of daily activity as requested for management and assist management in monthly reports as requested.
- Managing and handling pending cases (if any) to the next shift colleagues
Medical Claims Processor
NAS NEURON HEALTH SERVICES LLC.
10.2018 - 11.2021
- Taking a lead role in assuring that the assigned tasks to the team are completed within the allocated time frame.
- Entering and processing/adjudicating claims/approvals on direct billing in NAS operational software system as per the terms and policy of the organization.
- Achieving required processing targets assigned by the team leader on a daily, weekly and monthly basis.
- Responding to providers and beneficiaries about coverage and limitations. Scrutinize each and every policy of different payers/insurances that we are handling.
- Give verbal approval for inpatient admission, emergency procedure, and laboratory under the scope of insurance policy.
- Analyze and interpret documents sent to us for initial adjudication within turn over time.
- Fully versed with the medical insurance policies for various groups/beneficiaries.
- Assess request from different providers by technically auditing the claims to determine the extent of insurance coverage and medical data completion to justify the case.
- Follow up cases; obtain medical reports and results prior to authorization. Ensure claims are properly approved or rejected applying both members insurances policy and medical justification.
- Adjudicates for allocation of deductible , co-payments. Facilitate/expedite pending request for inpatient cases to our medical team.
- Interpret insurance policy if additional benefit is included like vaccination, optical, psychiatry, dental, alternative medicine.
Medical Claims Processor/Billing Officer
NMC ROYAL HOSPITAL/NMC DSC
12.2013 - 08.2018
- Check patient's insurance details, validity, card format , card co-payment deductible and card coverage
- Enter claims data into system while interpreting coding and understanding medical terminology in relation to diagnoses and procedures.
- Validates and support the deduction and discounts performed with proper documentation.
- Assess the diagnostic procedure done, treatment or services and medications given for inpatient and outpatient.
- Follows adjudications policies and procedures to ensure payment of claims. Communicates with other Medical Team with regards tot he claims clarification and ending.
Inventory Clerk
STAR APPLIANCE CENTER INC
11.2011 - 04.2012
- Ordered parts and maintained adequate inventory.
- Educated customers on use, care and adjustments of appliances.
- Facilitated repairs by disassembling defective and broken equipment.
- Disassembled, repaired and reassembled equipment in good working order.
Nurse
LEMERY DOCTOR'S MEDICAL CENTER
07.2007 - 08.2009
- Responsible for rendering profession nursing care to patients within the assigned units of the hospital.
- Perform a variety of supportive and technical nursing skills and utilizes a range of equipment when carrying out specific treatments, diagnostic, therapeutic, and supportive measures.
- Initiates and performs a range of nursing measures based on patients needs related to physical and mental comforts, positioning and mobilization, nutrition, hydration, bowel and bladder elimination, care of the skin and wound support of respiration , hygiene, communication. Any other physical and bodily function.
- Provide a safe, therapeutic, personalized and psychological environmental for patient care.
- Established therapeutic relationship with patients, families and elicits their participation in care.
- Plans and provides patients/family teaching during daily care relative to understanding of the illness and treatments.
- Initiates and actively participates in CPR.
- Reports and documents significant information through established oral written process.
Education
Certificate III - CERTIFICATE III IN INDIVIDUAL AND AEGING SUPPORT
VICTORIAN INSTITUTE OF EDUCATION
741 GEORGE ST. HAYMARKET NSW08.2025
Bachelor of Science - NURSING
LYCEUM OF BATANGAS
PHILIPPINES04.2007
Skills
- Good communication and interpersonal skills
- Capable to advance and progress in the work environment
- Strong analytical and problem-solving skills
- Ability to do multi-tasking and can work independently
- Ability to work in fast paced environment
- Good time management skills
- Well organize with strong attention to detail
- Professional in handling work responsibilities
Certification
- REGISTERED NURSE PHILIPPINES (2016)
Timeline
Associate Preauthorization Medical and Life Claims
SUKOON INSURANCE
01.2023 - 07.2023
Insurance Executive
MEDCARE HOSPITAL SHARJAH
01.2022 - 12.2022
Medical Claims Processor
NAS NEURON HEALTH SERVICES LLC.
10.2018 - 11.2021
Medical Claims Processor/Billing Officer
NMC ROYAL HOSPITAL/NMC DSC
12.2013 - 08.2018
Inventory Clerk
STAR APPLIANCE CENTER INC
11.2011 - 04.2012
Nurse
LEMERY DOCTOR'S MEDICAL CENTER
07.2007 - 08.2009
Certificate III - CERTIFICATE III IN INDIVIDUAL AND AEGING SUPPORT
VICTORIAN INSTITUTE OF EDUCATION
Bachelor of Science - NURSING
LYCEUM OF BATANGAS
- REGISTERED NURSE PHILIPPINES (2016)
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