Ahmed Abdelrahim

Professional Coding Supervisor with a comprehensive understanding of Payer-Provider dynamics, uniquely developed through a career transition from Insurance Medical Review to coding and approval supervisor. With over 7 years of expertise in Medical Coding in the Saudi healthcare sector, I possess a dual perspective that enables the anticipation of payer behaviors, ensuring seamless clinical-to-financial workflows and maximum Revenue Integrity. I am a specialist in ICD-10-AM, CPT, and ACHI, ensuring 100% Coding Accuracy and full compliance with CHI Regulations and NPHIES platform standards (SBS V3).

Expert in conducting Internal Medical Auditing and leading Clinical Documentation Improvement (CDI) initiatives to eliminate billing errors. A results-driven leader proficient in KPI Tracking and DRG implementation, dedicated to mentoring coding teams to maximize reimbursement and optimize complex Saudi billing cycles.

Coding And Approval Supervisor at Tadawi Medical Company (2019-04 – Present)

Led the end-to-end NPHIES implementation and mapping project with comprehensive management of complex pricelists and regulatory compliance.

• Led the end-to-end NPHIES implementation and mapping project, transitioning from initial stages to SBS V3 for the entire group, managing over 34 complex pricelists.
• Executed monthly SFDA code updates, ensuring 100% compliance with GTIN and generic code standards to prevent billing discrepancies.
• Mastered the mapping and implementation of MOH (Ministry of Health) pricelists, ensuring seamless integration with group-wide systems.
• Headed the Medical Approval and Medical Audit teams, establishing a high-performance culture that reduced initial claim rejections by 90%.
• Supervised and mentored a large team of medical coders, ensuring coding accuracy across all group facilities using ICD-10-AM and CPT standards.
• Conducted high-level negotiations with insurance companies to resolve complex claim disputes and maximize reimbursement.
• Utilized advanced data analysis to identify root causes of rejections, resulting in a sustainable increase in the group's net income.

Medical Auditor at Tabark Pediatric Hospitals (2014-01 – 2016-02)

Performed comprehensive medical audits and quality assurance for pediatric hospital facilities.

• Performed comprehensive medical audits for 3 hospital branches to guarantee error-free insurance claims.
• Conducted Pre-submission reviews to proactively identify and resolve potential rejection causes.
• Ensured full compliance with insurance provider protocols and medical necessity guidelines.

Medical Reviewer at MedRight Insurance Co. (2011-03 – 2013-12)

Executed technical and medical revisions for diverse claim types across multiple healthcare service categories.

• Executed technical and medical revisions for diverse claim types, including Inpatient (Hospitals) and Outpatient services (Labs, Radiology, Polyclinics, and Pharmacies).
• Verified Medical Necessity and technical documentation for multi-disciplinary claims to ensure accurate reimbursement.
• Analyzed clinical data to resolve billing disputes and ensure Claim Integrity.

Medical Pre-Approval Specialist at Operations Insurance Co. (2009 – 2011)

Managed the end-to-end Pre-Approval process for various medical services and acted as liaison between healthcare providers and insurance company.

• Managed the end-to-end Pre-Approval process for various medical services, ensuring treatments aligned with medical necessity and insurance policy coverage.
• Acted as a primary point of contact between healthcare providers and the insurance company to expedite urgent approvals and resolve authorization discrepancies.

Medicine – Faculty Of Medicine Ain Shams