Buena Fe Mariel Diaz
Pateros
Summary
Registered Nurse with years of experience in utilization management, pre-authorization, clinical review, insurance eligibility, and revenue cycle management. Skilled in clinical documentation review, payer coordination, denial prevention, and medical necessity review using InterQual criteria. Detail-oriented, dependable, and experienced in both onsite and medical virtual assistant roles supporting U.S. healthcare systems.
Overview
10
10
years of professional experience
1
1
Certification
Work History
Eligibility Coordinator
Trabecular Medical Group
09.2024 - 01.2026
- Verified insurance eligibility, benefits, and authorizations via phone, fax, and payer portals
- Documented copays, deductibles, co-insurance, OOP, LTM, and financial responsibilities accurately
- Coordinated with clinical teams regarding rescheduling due to authorization or benefit limitations
- Performed quality assurance audits to ensure denial prevention and accurate patient account processing
Pre-bill Denial Nurse - Accounts Receivable Executive
Omega Healthcare
Pasig City
04.2023 - 09.2024
- Reviewed clinical documentation and authorization requests based on urgency
- Conducted medical necessity reviews using InterQual criteria
- Prepared appeals supported by clinical documentation when criteria were not initially met
- Coordinated with payers through calls, portals, fax, and peer-to-peer review processes
- Responded to payer clinical inquiries to expedite approvals and prevent denials
Clinical Nurse Reviewer
Access Healthcare
Pasay City
10.2020 - 03.2023
- Performed pre-certification, inpatient, and retrospective reviews
- Conducted medical necessity and benefit determination reviews
- Collaborated with providers to optimize patient outcomes and benefits
- Coordinated discharge planning and continued stay reviews
- Prepared written correspondence in compliance with UM policies
Clinical Auditor
ISTA Personnel Solutions
Makati City
02.2020 - 10.2020
- Analyzed medical records for quality of care, medical necessity, and insurance eligibility
- Applied critical clinical judgment in evaluating documentation accuracy
- Collected and validated medical data for review escalations
Nurse Associate
EXL Services Philippines, Inc
MOA, Pasay City
11.2018 - 11.2019
- Reviewed clinical documentation for pre-authorization requests
- Applied ICD-10 codes and clinical criteria aligned with regulatory standards
- Coordinated resolutions with internal and external clinicians
Clinic Nurse
Active One
Pasay City
04.2018 - 11.2018
- Managed daily patient care operations and staff scheduling
- Provided triage guidance and supervised patient evaluations
- Ensured compliance with clinical policies, safety, and equipment maintenance
Clinical Appeals Coordinator / Certified Pharmacy Technician
Optum Global Solutions Inc
UP-Ayala Technohub
09.2016 - 04.2018
- Reviewed appeals using nationally recognized clinical criteria
- Evaluated prescription and pharmacy data for medical necessity
- Prepared appeal documentation and ensured compliance with standards
Tier II Representative
Convergys
UP-Ayala Technohub
09.2015 - 03.2016
- Handled healthcare claims and benefit inquiries
- Provided pre-authorization guidance to providers
- Maintained SLA compliance in a high-volume environment
Education
Bachelor of Science - Nursing
Our Lady Of Fatima University
01.2013
Skills
- Utilization Management & Clinical Review
- Insurance Eligibility & Benefits Verification
- Pre-Authorization & Referrals
- Denial Management & Appeals
- InterQual Criteria (Acute, Procedures)
- Medical Records & Chart Review
- Revenue Cycle Management (RCM)
- ICD-10 Coding Knowledge
- MS Office & CRM Systems
- Strong Communication & Decision-Making
Certification
- Registered Nurse: Philippine State Board of Nursing
- Basic Life Support (BLS) certified by American Heart Association
- Licensed IV Therapist by ANSAP
- Disaster Nursing, The Philippine National Red Cross, Valenzuela City Red Cross Chapter, Member, January 2013
- University of the Philippines Ugnayan ng Pahinugod- Philippine General Hospital, Emergency Room Volunteers Program, April 2018
Personal Background
- Date of birth: August 23, 1993
- Place of birth: Mandaluyong City
- Gender: Female
- Civil status: Single
Timeline
Eligibility Coordinator
Trabecular Medical Group
09.2024 - 01.2026
Pre-bill Denial Nurse - Accounts Receivable Executive
Omega Healthcare
04.2023 - 09.2024
Clinical Nurse Reviewer
Access Healthcare
10.2020 - 03.2023
Clinical Auditor
ISTA Personnel Solutions
02.2020 - 10.2020
Nurse Associate
EXL Services Philippines, Inc
11.2018 - 11.2019
Clinic Nurse
Active One
04.2018 - 11.2018
Clinical Appeals Coordinator / Certified Pharmacy Technician
Optum Global Solutions Inc
09.2016 - 04.2018
Tier II Representative
Convergys
09.2015 - 03.2016
Bachelor of Science - Nursing
Our Lady Of Fatima University