- Specialized in MCC, as Medical Claims Reviewer, Insurance Doctor, Medical Claims assessment with:
- Medical Justification
- Within CCHI regulations
- Within specific company policy and Mednet policy
- Excellent record on high profile claims management, cost reduction, fraud detection.
- Excellent progress in short space of time, deep knowledge.
- Excellent typing speed within time frame and all records embedded in the Mednet computer system.
- Reference: Dr Afsar Ehtisham, General Manager: Mednet SA.
- Strengths with on the ground actual experience:
- Analysis of pre-approvals, negotiation/justification with medical providers, responsibility for approval and placing into system.
- Basic Medical Advice
- Communication with insured members
- Best presentation on application of new products and their presentation as required.
- Confidentiality
- Inpatient Cases
- Training
- Incoming / outgoing pre- authorization requests.
- Knowledge and stress on the rapid turnover time and guidance/tips and systems on how to achieve this.
- Knowledge on all sides of the insurance spectrum Insurance company, medical provider, insured member, TPA and private company with best loss ratio in favour of TPA/Reconciliation.
- Day to day internal communication and coordination as per company requirements.
- Fraud detection.
- Approvals and Pre Approvals
- Covered\ uncovered services.
- Price lists.
- Claims Software Development with: auto select. Future development: predictive text and actions.
- Communication with providers.
- Working with teams.
- Worked in Al Mursalat Polyclinic from 1st April 2014 - Sept 2014
- As Insurance Manager and Business Development Manager
- Reducing claim denial/ rejection, losses and improving revenue.
- In depth knowledge of requirements of the insurance companies for best claims approval.
- Finalization of medical claims and sending to insurance companies.
- Review Medical Claims of all Medical departments as fully justified and accepted by insurance companies to reduce rejections and improve revenue of clinics.
- Working with teams.
- Working with /guiding doctors about best UCAF, insurance practices in KSA.
- Training insurance staff.
- Worked in Asiacare with designation:
Assistant Manager Claims from Nov 18, 2015 to April 1st, 2016
- All the above plus
- Working with policy
- Policy development
- Advanced fraud detection
- Reimbursements
- Implementing new ideas
- Deep evaluation
- Benchmarking
- OPD and IPD
- Fraud Detection
Currently working in Al Rubban Medical Center, Dammam as Insurance Manager and Business Development Manager from April 13, 2016 to October 24th, 2022. Work includes:
. Claims processing / submission
. Reconciliation
. Communication with insurance companies
. In charge of new software system deployment and automation
. Recruitment / Human Resources
. Reduction in rejections
. Development of medical packages and implementation
. Development of latest price lists
. Insurance Contract renewal negotiations.
. Developing low cost drug price lists.
. Staff salaries.
. Building, training and developing the team
. Contracting new Insurance Companies
. Complete claims checking for medical, covered services and technical.
. Implementation and work on Eclaims.
. Deployment implementation of DHS and Waseel for BUPA, SAICO, MALATH, Tawuniya and Al Rajhi. Streamlining processes, workforce and going paperless.
- Communication with all insurance companies including: BUPA, Tawuniya, Medgulf, AXA. GlobeMed, Mednet, Nextcare etc
Deep knowledge of application of CCHI guidelines for claims.
With excellent communication skills both with clients and partners.
Good contacts with many insurance companies.
Best negotiation between insurance company and clinics regarding claims.
Complete experience in client \ customer \ patient service skills in insurance environment within KSA.
Biggest advantage is dual sided knowledge of strategies adopted by both TPA and Medical Providers in order to extract the highest level of benefit for the TPA or clinics respectively.
