Looking for a job

Princess Pauline Dela Serna

@princesspaulinedelas

Message

Medical content developer at Lyric Health who researched and developed clinical content for the CCM suite of offerings.

Philippines

Message

What I'm looking for

I’m looking to enhance my knowledge, skills, and career experience through a position in an innovative institution that provides continuous advancement in medical coding, health informatics, nursing practice, and education.

At Lyric Health Inc. (Previously Change Healthcare), I researched and developed clinical content for new and revised business rules to expand the CCM suite of offerings. I reviewed CPT, HCPCS, and ICD content against clinical sources and presented research findings to the team and medical directors.

At Optum Global Solutions / United Health Group, I reviewed healthcare claims for coding accuracy, medical necessity, and appropriate reimbursement. I also investigated claims flagged through payment integrity edits and provider referrals.

Most recently, at Boucher Advisory Group, I reviewed aged care documentation against Australia’s Aged Care Quality and Safety Commission guidelines and identified reportable incidents under SIRS. I’m looking to enhance my knowledge, skills, and career experience in medical coding, health informatics, nursing practice, and education.

Experience

Work history, roles, and key accomplishments

Registered Nurse Auditor

Boucher Advisory Group

Jul 2026 - Sep 2026 (2 months)

Performed clinical review and analysis of aged care documentation based on guidelines of the Aged Care Quality and Safety Commission. Identified incidents under SIRS and conducted triangulation of data lapses.

Clinical Review Aged Care SIRs Data Analysis Incident Reporting

Clinical Editing Analyst

Specialized Solutions Services

Mar 2026 - Apr 2026 (1 month)

Managed provider appeals related to clinical edits, multi-surgery claims, and DLP, ensuring adherence to procedures and timelines. Identified and resolved process issues for consistent application of clinical editing criteria.

Clinical Editing Appeals Management Provider Appeals Process Improvement

Medical Case Evaluator

Health Metrics Inc.

Jun 2024 - Jan 2026 (1 year 7 months)

Analyzed and assessed medical visits, records, and files of patients based on maritime and principal guidelines. Coordinated with Principals and Medical Directors to ensure accuracy and quality review.

Medical Evaluation patient assessment Quality Review Communication Skills

Medical Content Developer

Lyric Health Inc.

Oct 2021 - Jul 2025 (3 years 9 months)

Provided research, analysis, and clinical content development for new and revised clinical content to expand the CCM suite. Reviewed clinical sources including CMS manuals, AMA publications, and code updates.

Medical Coding CPT HCPCS ICD 10 CMS Guidelines Familiarity AMA Guidelines Clinical Content Development Research

Appeals Writer Specialist

Conifer Health Solutions

May 2020 - Oct 2021 (1 year 5 months)

Validated dispute reasons following Explanation of Benefits review and generated appeals for denied or underpaid claims. Ensured appropriate billing charges were captured and documented in accordance with policies.

Appeals Claims EOB Billing Regulatory Compliance

Clinical Analyst

UST Global Inc.

Jan 2018 - May 2020 (2 years 4 months)

Reviewed claims and appeals according to insurance guidelines by comparing ICD-10, CPT, and HCPCS codes. Performed daily audits on client data for coding accuracy and analyzed provider appeals.

Medical Coding Claims Review Appeals ICD 10 CPT HCPCS Audit

Private Duty Nurse

Private Clients

Jun 2013 - Dec 2018 (5 years 6 months)

Provided private duty nursing care to pediatric, geriatric, and medical-surgical patients on an on-call basis.

Nursing Patient Care Pediatrics Geriatrics Medical Surgical Nursing

Clinical Reviewer

Optum Global Solutions

Dec 2015 - Dec 2017 (2 years)

Performed pre-payment and post-payment review of healthcare claims to identify fraud, waste, abuse, and billing errors. Conducted medical coding audits and payment integrity investigations.

Medical Coding Claims Review Fraud Detection Payment Integrity CMS Regulations Audit

Receptionist / Out-Patient Nurse

The Medical City Clinic

Jun 2015 - Dec 2015 (6 months)

Served as a receptionist and out-patient nurse, handling patient intake and providing nursing care in an outpatient setting.

Nursing Patient Care Reception outpatient care

EFL Instructor

EforK, Inc. IBIZ Academy

Apr 2014 - Apr 2015 (11 months)

Provided English language instruction to Korean students through an online learning platform, fostering language proficiency and effective communication skills.

English Teaching Online Teaching Communication Skills

Nurse Trainee

St. Luke's Medical Center

Mar 2013 - Jul 2013 (4 months)

Completed post-graduate nurse training and preceptorship at a JCI accredited institution, with exposure to obstetrics, gynecology, newborn care, and post-partum management.

Nursing Obstetrics Gynecology Newborn Care Postpartum Care