Assistant Manager- Claims Operations
MEDNET BAHRAIN ( Munich Re Company)
Total years of experience :18 years, 0 Months
Health Insurance Claims (Operations, Quality Assurance and Training) :
Handling a Team of claims processors on day to day basis and providing assistance in all reviews related to medical/surgical billings for reasonable and necessary charges, medical coding of operative reports, procedures, and multiple and complicated surgeries.
Assisting Medical department in providing second review of bills on which providers question the appropriateness of payments authorized.
Responds to questions, telephone calls, and letters regarding the company's cost containment program, utilization review decisions, and reductions.
Supervising all processes related to Medical billings in terms of Auditing, evaluation, processing, and validation of claims, with regards to eligibility as per the company's terms and conditions.
Communicate policy and rules to Reimbursement Claims evaluations team to finalise claims as per terms and conditions.
Supervising all types of Training and assisting claims staff on ICD-9, ICD 10, CPT coding, quality health care cost containment and utilization reviews.
Assists and advises claims staff concerning the monitoring of claimants' medical treatments.
Establishes channels of communication with providers to familiarize them with company guidelines.
Internal Business Process and Team Management:
Supervising team functions of the entire organisation, viz. manpower planning, interview & selection, induction, performance appraisal, training, etc.
Mentoring & monitoring the performance of team members to ensure efficiency in process operations and meeting of individual & group targets.
Creating and sustaining a dynamic environment that fosters development opportunities and motivates high performance amongst Team members.
Communicate performance data as such would be related to quality/quantity aspects to allow for proper recognition of work evaluations.

Active involvement in the implementation and continuous improvement of TAT.
Provide feedback on their output and performance.
Develop and recommend improvement of facilities, equipment, or procedures to improve safety, quality, and efficiency.
Monitor usage of utilities to ensure efficiency; establish a culture of continuous improvement in a safe working environment.
Risk Consulting and Internal Audits
Preparation of the Drafts and Final Internal Audit Reports.
Preparation of Audit Plans, Audit programs, conducting Risk assessments before execution of audits.
Preparation and Conducting Gap Assessment reports based on Corporate Governance and carrying out special reviews.
Conduct Audit work based on established Audit plans and execute the Audit in accordance with established standards ensuring completion within prescribed budget, time and scope parameters.
Present objective and independent Audit opinion on the adequacy of Internal controls in accordance with established Audit standards, including presentation of findings and recommendations to Audit management.
Conduct risk assessment of assigned department or functional area in established/required timeline.
Review the suitability of internal control design. Conduct audit testing of specified area and identify reportable issues and dimension of risk.
Conducting kick off meetings, exit meetings with the Senior Management of the client.
Process audits such as Procurement, Marketing, Revenue, Human Resources, Finance, Legal etc.
Conducting ad-hoc activities such as preparation of Internal Audit proposals, performing Risk Management prior to acceptance of engagement, follow up on invoices on the client and maintaining chargeability.
Follow-up on audit findings raised by regulatory and divisional Audits.
Planning Internal audits on Quarterly basis to meet the QMS requirements and ensure that all the process within the organisation follows ISO 9001; 2008 Quality Management Systems as per international guidelines.
Preparation Corrective and Preventive action plans for Non conformance raised during internal Audits.
Implementing QMS (ISO 9001:2008)
Ensuring Successful Implementation of Quality Management System
Ensuring that all necessary QMS processes are adequately defined, effectively deployed, and continually kept up.
Coordinating through one or more project teams who define processes relating to their areas of responsibility and involving appropriate functional managers.
Assisting MR in providing training for developing the ISO 9001:2008 QMS processes requirements and related documentations to ensure adequate understanding of what is required within the organisation.
Responsible to ensure that there is effective Document control Function within all the related processes
Ensuring effective coordination of Internal Auditors to monitor the compliance and effectiveness of QMS
Planning Internal audits on Quarterly basis to meet the QMS requirements and ensure that all the process within the organisation follows ISO 9001; 2008 Quality Management Systems as per international guidelines
Preparation and successful execution of Internal Audit Plan as per Internal audit schedule
Preparation Corrective and Preventive action plans for Non conformance raised during internal Audits
Distribution of Internal audit reports to all the processes after internal audits and discussion with Functional Managers about the open issues (NCR’s) thorough successful resolution.
Claims Management
Overseeing insurance claims based on coverage, appraisal, and verifiable damage.
Reconciling the claims as per the prescribed claim process.
Effectively following-up with the claim investigators, field staff for speedy and effective claim settlement.
Ensuring all enquiries/payments are dealt with quickly, keeping the files & documents updated.
Carrying out interaction with the clients and attending their grievances.
Experience in Handling ICD 9& ICD 10 coding cases along with conversions of diseases into ICD codes.
Process Management
Mapping business requirements and coordinating in developing and implementing processes.
Analysing the data and providing the information that helps in overall growth of the organisation.
Removing unnecessary procedures in processes; ensuring uniformity in the process understanding at the client’s and the organization’s end.
Monitoring the overall functioning of processes, identifying improvement areas and implementing adequate measures to maximize customer satisfaction level.
Team Management
Supervising team functions of the entire organisation, viz. manpower planning, interview & selection, induction, performance appraisal, training, etc.
Mentoring & monitoring the performance of team members to ensure efficiency in process operations and meeting of individual & group targets.
Creating and sustaining a dynamic environment that fosters development opportunities and motivates high performance amongst Team members.
Ensuring Successful Implementation of Quality Management System Ensuring that all necessary QMS processes are adequately defined, effectively deployed, and continually kept up. Coordinating through one or more project teams who define processes relating to their areas of responsibility and involving appropriate functional managers. Assisting MR in providing training for developing the ISO 9001:2008 QMS processes requirements and related documentations to ensure adequate understanding of what is required within the organisation. Responsible to ensure that there is effective Document control Function within all the related processes
- Business planning - Setting project objectives and execution - Problem Analysis - Solution finding through application of various tools. - project reporting