Shadi Elmuttalib

Healthcare professional with many years of experience in the health industry, I have driven significant improvements in compliance and fraud prevention as Audit Manager leading to an increase in audits completed in 12 months.

Medical Officer - Al Gafaar Clinic

(2021-05 - 2023-05)

• Keeping records of the patient's disease, operations or treatments
• Prescribing laboratory tests and interpreting the results obtained
• Conducting face-to-face clinical evaluations on the impact of a patient's injury
• Prescribing medication or drugs, including dosage and usage and dispensing medication in accordance with governmental guidelines
• Updating General Practitioners of their patient's progress
• Maintaining medical quality assurance and quality control standards
• Supervising and training medical personnel or trainee Doctors

Audit Manager - Oman Insurance Company

(2014-02 - 2019-12)

• Develop and implement departmental processes to ensure compliance with contractual guidelines
• Oversight the quality assurance process related to rebuttals/acceptance of quality results to ensure the timely and accurate handling of claims and responses
• On an ongoing basis, assess the staffing needs of the department based on the volume of work and the departmental production goals, and make adjustments to maintain compliance
• Establish departmental production and quality goals for each function within the department, and monitor and track performance
• Oversight and review compliance reports for claims to track regulatory compliance and provide management reporting
• Serve as a resource to departmental supervisors/staff for questions concerning contractual interpretation, claims administration guidelines, and workflow and operational issues
• Serve as a liaison in communicating with other departments, business associates, health plan partners and state and federal entities
• Manage and coordinate any testing needed for change/upgrades to claims platform
• Participate/collaborate with both internal teams associated with Network Operations and external departments within the hospital

Insurance Manager - Oman Insurance Company

(2014-02 - 2019-12)

• Develop and implement departmental processes to ensure compliance with contractual guidelines
• Oversight the quality assurance process related to rebuttals/acceptance of quality results to ensure the timely and accurate handling of claims and responses
• On an ongoing basis, assess the staffing needs of the department based on the volume of work and the departmental production goals, and make adjustments to maintain compliance
• Establish departmental production and quality goals for each function within the department, and monitor and track performance
• Oversight and review compliance reports for claims to track regulatory compliance and provide management reporting
• Serve as a resource to departmental supervisors/staff for questions concerning contractual interpretation, claims administration guidelines, and workflow and operational issues
• Serve as a liaison in communicating with other departments, business associates, health plan partners and state and federal entities
• Manage and coordinate any testing needed for change/upgrades to claims platform

Supervisor Case - Oman Insurance Company

(2014-02 - 2019-12)

• Analysing and validating audit findings according to payer regulations and payer processing guidelines/provider contracts
• Communicating with management on audit findings, assist with error validation process
• Assisting in the management and operations of an audit, reviewing paid medical claims to determine whether an overpayment exits due to coordination of benefits issues
• Developing and validating workflows and communication tools to best enhance production, client satisfaction, and quality assurance
• Working with IT support staff to develop and implement technological improvements that will support the audit process
• Preparing/analysing reports of audit reviews and performance issues with a focus on continuous quality improvement initiatives
• Identifying and recommending corrective action plans and training of processes or techniques to meet accuracy requirements
• Responding professionally and accurately to all client/provider inquiries within required timelines
• Clinical Care Coordination/Facilitation: coordinating multiple aspects of care to ensure the patient progresses
• Continuity/Transition Management: transitioning of the patient to the appropriate level of care needed
• Utilization/Financial Management: managing resource utilization and reimbursement for services
• Performance & Outcomes Management: monitoring, and if needed, intervening to achieve desired goals and outcomes for both the patient and the hospital
• Research & Practice Development: Identifying practice improvements and using evidence based data to influence needed practice changes
• Spearheaded technical leadership in the Strengthening Local Health Systems (SLHS) Activity, ensuring the effective implementation of health programs. Led a multidisciplinary team, driving innovation and achieving project objectives with a focus on sustainable health system strengthening

Clinical attachment • Teaching - South Tyneside Hospital - New Castle

(2014-04 - 2014-05)

Resubmission Officer - Al Noor Hospital

(2013-05 - 2013-02)

• Analysing the rejection from the XML remittance Advice
• Sort out the rejection as per denial reason
• Sending the rejected claims for the respected doctors for justifying the claims if necessary and follow up with the doctors within the specified time
• Preparing rejected claims for resubmission
• Submitted the claims with proper codes and format to insurance companies
• Make sure that the final rejection is at its minimal level
• Should meet the resubmission productivity targets within the stipulated time for all insurance companies
• Ensure that clinical procedures are implemented in accordance with policies
• Ensure that business decisions and processes are documented in a professional way
• Evaluate and develop tools for a proper evaluation of medical and surgical claims and management of clinical cases while applying the wording of the policy
• Ensure that while performing the medical evaluation of the claim files to have the medical ethics respected at all times

Medical Review Officer - Daman National Health Insurance Company

(2008-06 - 2009-01)

• Ensure that clinical procedures are implemented in accordance with policies
• Ensure that business decisions and processes are documented in a professional way
• Evaluate and develop tools for a proper evaluation of medical and surgical claims and management of clinical cases while applying the wording of the policy
• Ensure that while performing the medical evaluation of the claim files to have the medical ethics respected at all times

MBA - Healthcare Management - Geneva Business School (2015-12 - 2017-06) Dubai UAE

Certification - Communication - Royal Australian College (2009-12 - 2010-06) Brisbane

M.B.B.S - Medicine - Dow University Of Health (2000-08 - 2006-06)