Summary
Overview
Work History
Education
Skills
License
Character Reference
Timeline
Generic

Lawrence Allen Victoria

Clinical Denials Clinician / Appeals Nurse / Clinical Claim Review RN
Pasig City

Summary

Experienced Appeals Specialist effectively managing high caseloads in fast-paced environments. A driven and adaptable professional with over 9 years of clinical experience, possessing exceptional planning and problem-solving abilities. Diligent nursing professional with demonstrated success in delivering top-notch patient care. Able to swiftly adapt to dynamic patient needs and environmental conditions with a strong team-oriented and reliable approach. Possesses expert healthcare knowledge, communication skills, and sound clinical judgment. Well-versed in processing healthcare disputes, reviewing cases to determine facts, and reading and interpreting medical records, and formulating compelling clinical appeals and letter.

Overview

12
12
years of professional experience
10
10
years of post-secondary education

Work History

Clinical Claim Review RN

Optum
09.2024 - 03.2025
  • Retrospective review of medical claims and application of medical and reimbursement policies
  • Reviewed appeal requests from denied claimants, making determinations based on clinical guidelines and individual case factors.
  • Implemented quality control measures in the claim review process to reduce instances of overpayment or underpayment of benefits.

Clinical Denials Clinician

Conifer Health Solutions
06.2022 - 08.2024
  • Reviews and assesses medical records and claims to ensure proper patient care and accurate billing as per healthcare standards.
  • Evaluates the need and legitimacy of medical treatments and procedures that insurance denied.
  • Has knowledge of billing codes and guidelines.
  • Uses clinical insights and understanding of healthcare laws to support patient interests.
  • Challenges and corrects wrongful or inaccurate denials to ensure coverage for necessary medical services.
  • Promotes fairness and precision in healthcare billing and insurance processes.
  • Skilled in navigating Electronic Medical Records (EMR) systems and patient databases effectively.
  • Serves as a liaison among healthcare providers, patients, and insurers.

Operating Room/Recovery Room Nurse

Rizal Medical Center
12.2017 - 05.2022
  • Managed patients recovering from medical or surgical procedures.
  • Developed personalized care plans to address each patient''s unique recovery goals and challenges.
  • Educated patients and families about post-operative care, answering questions, addressing concerns, and promoting adherence to discharge instructions.
  • Assisted in complex surgeries with precise execution of tasks, ensuring optimal outcomes for patients.

Staff Nurse(OB/Surgical Ward)/Operating Room Nurse

World Citi Medical Center
10.2012 - 8 2017
  • Directed patient care by initiating and following through with plan of care, continuing care, and discharge instructions.
  • Collaborated with interdisciplinary team members for comprehensive patient assessments and treatment plans.
  • Provided direct support to surgical team during procedures.
  • Performed pre-operative assessments to prepare patients for surgery.
  • Monitored patients during recovery and provided post-operative care.
  • Assisted physicians in operating room by providing necessary supplies and equipment.

Education

Bachelor of Science - Nursing

Centro Escolar University
04.2001 - 03.2011

Skills

  • Analytical Thinking

  • Data Integrity

  • Continuous learning mindset

  • Appeals Process Proficiency

  • Clinical assessment

  • Clinical Documentation

License

  • Registered Nurse

Professional Regulation Commission

Board of Nursing, Philippines

License Number: 0713745

July 2011

Valid until: October 2026


  • Registered Nurse

The University of the State of New York

Education Department

License Number: 918177

November 2023

Valid until: October 2026



Character Reference

  • Charles Veloso

             Conifer Health Solutions

              Team Leader

                  +63 (906) 282 1355


  • Nimfa Dumrigue

            Conifer Health Solutions

               Subject Matter Expert (SME)

                  +63 (998) 853 8295 

Timeline

Clinical Claim Review RN

Optum
09.2024 - 03.2025

Clinical Denials Clinician

Conifer Health Solutions
06.2022 - 08.2024

Operating Room/Recovery Room Nurse

Rizal Medical Center
12.2017 - 05.2022

Staff Nurse(OB/Surgical Ward)/Operating Room Nurse

World Citi Medical Center
10.2012 - 8 2017

Bachelor of Science - Nursing

Centro Escolar University
04.2001 - 03.2011

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Lawrence Allen VictoriaClinical Denials Clinician / Appeals Nurse / Clinical Claim Review RN