2011
Bachelor of Science in Nursing
University of the Cordilleras
More Info About Me
Fraud Risk & Healthcare Operations Specialist with 8+ years of experience in fraud investigation, claims verification, and customer service within insurance and healthcare industries. Recognized for 100% quality scores over 6 years, expertise in detecting anomalies in claim patterns, and proven ability to communicate effectively with providers, members, and internal teams. Adept at using Pega Case Manager, Tableau, and other analytics tools to drive process improvements and support compliance. Awarded for perfect attendance and reliability, and trusted to support system testing, UAT, and new hire training.
My Skills and Competencies
Social Media Management
Medical Virtual Assistant
Data Entry
Content Creator
Certificates
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My Experience and Education
2016
-
2024
Sun Life Financial Asia Services Limited
(Investigative Services Representative II – Fraud Risk & Management)
· Reviews and analyzes member risk score reports and conducts fraud checks at both plan member and claim levels, identifying irregularities and preventing improper payouts.
· Verifies member’s medical and dental claims submissions with providers through calls, emails, and fax, ensuring accuracy and compliance.
Communicates with plan members via phone or email to obtain their signed consent, request receipts, and educate them on how to properly submit their claims online.
· Initiates adjustments and overpayment requests to the claims team when discrepancies were found.
· Creates detailed case summaries in Pega Case Manager for medical investigators’ (onshore team) review if fraud is suspected.
· Served as internal quality analyst; facilitates huddles to discuss errors and aligned the team with onshore quality standards.
2015
-
2016
HCL Technologies
(Apria Healthcare - Senior Customer Service Representative)
· Process DME orders based on prescriptions and verifies insurance eligibility.
· Liaise with insurance companies to confirm member coverage and qualifications.
· Supports new hires during ABAY process training and shares quality best practices.
2014
-
2015
Access Healthcare Services Manila Inc.
(Athena - Revenue Cycle Executive)
· Analyzes insurance claims for errors, discrepancies, and payment adjustments.
· Contacts insurance companies and claim adjusters to update claim statuses and resolve denials.
· Maintains detailed, accurate documentation in client systems.
My Services
Social Media Management
Analyzing engagement data, identifying trends in customer interaction and planning digital campaigns to build community.
Data Entry / Web Researcher
Search the Internet for information on a wide variety of topics.
Medical Virtual Assistant
Scheduling appointments, handling correspondence, and managing records.