Merlin Mathew

Presently working as an Insurance manager having good knowledge in empanelment, submission, re-submission, reconciliation, and Regulatory guidelines.

I also have a wide breadth of more than 13 yrs experience of the type which gives you the versatility to place me in a number of contexts with confidence that the level of excellence you expect will be met.

I can be reached at any time via my cell phone or email. Thank you for your time and consideration. I look forward to speaking with you about this employment opportunity.

• Managed to centralize three hospitals with a unified internal process by planning a successful strategic leadership. (Burjeel Hospital- Dxb &Shj, Medeor Hospital-Dxb)
• Monitoring the initial& final rejection rate, payer-wise rejection rate, CMI, IP & OP claims average.
• Monthly business review meeting with finance head, operation director, and senior management. Works closely with the finance and revenue cycle management team to create efficiency and consistency in claim processing and keep track of the data communication to finance.
• Plans organize, directs, and supervises the operations of the Insurance and the Coding section within the RCM in a manner that is compliant and efficient.
• Ensuring timely billing, pre-authorization, claims submission, re-submission, and reconciliation by resolving issues that arise during the process.
• Responsible for Denial Management by maintaining an accuracy of initial rejection percentage of less than eight percent.
• Restructured to implement a strong platform for system integration especially for RCM functions, which improves the RCM fast process of claims and payments in line with DHA guidelines.
• Empaneled New Business development contracts with Insurance Cos and also with Corporate international assistance groups for Second opinion schemes.
• Audited and fixed Process Flow gaps in operational issues that enhanced the patient flow along with loss of revenue.
• Trained and enhanced the profitability in IP DRG payment models and the importance of documentation, for members who play roles in the Revenue Cycle like physicians, front desk, Billing & Nursing.
• Ensuring timely billing, pre-authorization, claims submission, and re-submission by resolving issues that arise during process.
• Assist in the implementation of new processes & system application; develop related workflows and procedures; recommends upgrades or changes to the SAP Team.
• Responsible for Denial Management by maintaining an accuracy of initial rejection percentage less than eight percent, initial and five percent final rejection rate.
• Train employees and monitor ongoing productivity conduct performance improvement, and allocate daily job task to the team.
• In-depth knowledge of coding techniques and guidelines of medical coding and Proficient ICD-10 and CPT codes for diagnosis and procedure.
• Resolve and provide medical justification to the insurance companies for the rejected and audit cases.
• Monitor Cost estimates for Admission and outpatient treatments.
• Collaborates and conducts training activities for CDI, Resubmission, submission, and coding team physicians for the documentation and coding guidelines.
• Evaluate patient records for suitability, completeness, and correctness of health data, protected patient’s healthiness information for privacy.
• Liaise with the insurance companies/ TPA for new contracts and determine price schedules and discount rates.
• Updating the billing rules and the price list with the payer billing system.
• Mapping of HCPCS codes for the supplies including DME’s in Hospice system.
• Adjudicate along with the insurance companies over any disputed issues

• MBA (UWOL, UK)
• Certified Coding Specialist (CCS)
• Certified Coding Specialist (Physician) (CCS-P)
• CPC-H Certified Professional Coder-Hospital (AAPC)
• CCA Certified CodingAssociate(AHIMA)
• BSc- Microbiology (Garden City College, India)
• ICD 10 proficiency exam completed from AAPC