RCM Manager
Al Zaabi Group
Total years of experience :16 years, 8 Months
As a RCM manager responsible for Payer Relation Management.
Develop Value Cycle Management model to collaborate other departments to align KPI’s to
achieve better outcomes.
Develop strategies and bench marks for physician to achieve optimal Revenue focusing on value
based healthcare model.
RCM Department planning, resource allocation and on boarding.
Develop and implement SOP’s for the department.
Manage and Monitor physician average claim revenue to achieve optimal bench marks and
revenue performance.
Identify certain capacity and services from the SPC and enable to start billing missed
opportunities.
Manage physician case mix and unspecific assessments by trend analysis to bring more focus on
missed billing opportunities.
Manage front desk KPI’s for insurance registration and eligibility.
Training to create SMART front office focusing more on patient experience to sustain.
Manage Pre Approvals, Medical Coding and Billing.
Team calibration and improvement to enhance productivity.
Revenue Optimization by quality coding.
Manage Audit layers to ensure quality submission and minimize denials at first cycle.
Ensure submissions are complying with DOH regulation to be completed within 24hrs.
Manage Denials Audit and resubmission allocations, Control rejections.
Contract Management and unit pricing strategy.
Financial Planning with Senior Management.
Budget planning for the department.
A/R Management, Reconciliation Management and Closures.
Manage Reports for Revenue, Receivables and denials to present management.
Support IT team in developing in house BI tools and dashboard for Senior Management.
Support Management in Key strategic decision on business expansion.
Building Strategies, Account Management, Operations Management, Resource Control & Utilization, Project Management, Insurance Management, Claims Management, Medical Coding 7 Billing Services, RCM Services.
Project management on RCM for the below clients.
1. American Spine Center - DHCC: Revenue Cycle Management Services
2. Dr Sulaiman Al Habib Hospital - DHCC (Project Head): Denial Management & resubmission Services
3. Nation Hospital - Abu Dhabi: Revenue Cycle Management Services
4. Al Zahra Private Hospital - Dubai: Denial Management & resubmission Services
5. GHI (Gulf Healthcare International): Denial Management & resubmission Services
6. Eye Consultant - DHCC: Revenue Cycle Management Services
7. Al Borg Medical Laboratories - Abu Dhabi: Denial Management & resubmission Services
Manage and Optimize resources to generate better outcome with less cost in operations.
• Manage and implement HR planning to department to meet the right size of the manpower for better outcomes.
• Contract Management within Insurance companies and updating the billing system to capture correct agreed procedures and prices and update inclusion & exclusion rules to minimize denials.
• Manage eAuthorization to reduce the TAT's for high patient satisfaction.
• Implemented digital process for RCM by automation.
• Develop digital DRG business process and integrate to 3M grouper.
• Design and developed 3M data report within existing HIS in order to generate CMI (Case Mix Index).
• Implemented eAuthorization business process with in HIS modules to enable automation and reduce turnaround time and increase patient satisfaction.
• Pre billing and post billing process to ensure the revenue integrity.
• Implement full digital claim processing by automation which helps the organization achieve real time claim processing with minimum resources and increases the cash flow from payer, also help management to save cost of human resources.
• Support manager in controlling average claim for outpatient which is a key tool for payer satisfaction.
• Present Management RCM, Compliance and denial reports.
• Support General Manager in yearly budgets by HR planning and business key strategies.
• Integrate medical necessity tools at physician level in order to indicate clinical documentation GAP's for coding and billing. Develop full digital practice management system (eAuthorization, Claims Processing and uploading to DHPO, electronic posting and settlement for AR, Resubmission cycle for denial management, contract management)
• Manage and coaching resubmission team for denial management, policies and procedures of claims resubmission with digital process.
• Managing resubmission of denial claims with the standard time frame as per policies and procedure of department.
• Managing classification of denials and make the training to resubmission team.
• Working closely with Insurance Approvals and Claims Submission Team.
• Making sure that claim resubmissions are dealt with according to Insurance industry and DHA regulation.
• Working on complex cases that need experience and specialist knowledge.
• Maintaining quality and insurance service standards.
• Managing claims resubmission on time according to insurance agreed contract.
• Making reports and accurate information for reconciliation.
• Submitting KPI’s (Key Performance Indicator) of resubmission quarterly to higher management.
• Taking responsibility for the department’s productivity and targets.
• Prepare collection and rejection report and submit to higher management with percentage of complete rejection.
• Train staff for claims auditing and denial management.
• Manage coding cross walks like ICD to CPT, CPT to CPT, ICD to HCPCS
• Review denial reasons and audit the claims in order to generate justification for resubmission.
• Categorize the resubmission type based on the audit.
• Submit the audit report to finance team and generate the resubmission XML and upload to DHPO.
• Design and develop PBM in existing pharmacy module.
• Manage pharmacy team for taking online approvals with system.
• Support pharmacy for system related technical bugs
• The system guarantees money from insurance and reduces rejections to 0%.
• Implemented policies and procedures for PBM in pharmacy department.
• Train new pharmacist for PBM system.
• Technical support to pharmacy round the clock 24/7.
• Daily update dispenses of pharmacy claims on real time basis
• I am looking after all the department functionalities starting from patient encounter till the sign off with all insurance companies.
• Making reports and analyzing the rejections reasons and pattern of different insurance companies and doctors and recommending the steps to reduce and control the rejections.
• Directly responsible for the on time submission of invoices and resubmission of all rejected invoices to the insurance companies.
• Educating all the doctors regarding the E&M and insurance companies’ policies to all doctors.
• Educating staff regarding resubmission process.
• Clarifying all the queries of the staff as regards to CPT Group, CPT and ICD coding.
• Making sure that all resubmissions are done according to the contract, policy exclusion and tariff.
• Negotiating and signing the contract with insurance companies.
• Part of the JCIA accreditation team member.
• Looking after the business with corporate clients.
• Member of the senior executive committee.
• Clarifying all the doctors’ quires to the best of my knowledge and making the claims as accurate as possible to avoid rejections.
• Continuously training the staff of new updates in healthcare industry.
• In this short period of time, my major achievements are to manage submission of invoice in two batches and maintain the cash flow at high. Conduct almost 30 sessions of training to all doctors about EMR and insurance policies. Resubmitted all the rejected invoices of big insurance companies for the year 2012 and 2013, managed the SPC contract with 5 insurance companies, organized the department and assigned job responsibilities to all the staff, managed to sign a contract with software company regarding e-claims submission and resubmission.
• As head of resubmission unit analyzing denial management for IP, OP and Pharmacy claims from insurance companies.
• Making reports and analyzing the rejections reasons and pattern of different insurance companies and doctors and recommending the steps to reduce and control the rejections.
• Forwarding guidelines to all the hospital Department as to minimize the mistakes in billing and invoicing.
• Educating staff regarding resubmission process.
• Clarifying all the question of the staff as regards to DRG, CPT and ICD coding.
• Provider contract Management with Insurance and TPA companies.
Key Skills:
• Insurance Network Management
• Revenue Cycle Management
• eClaims Management
• Reconciliation
• Pre Authorization certification
• Internal Finance Auditing
• Hospital Pricing management
• Contract Management with CBD (Community Based Doctors)
• Training and Development for physicians
For the below projects working as GAP analyst also to implement new regulations from DHA for eclaims and make internal HIS system user friendly from physician desk to pharmacy.
1. eRx (ePrescription)
2. eAuthorization (PBM)
3. eClaim for DHPO
4. Electronic Medical Record Management (EMR): • Electronic medical records help to maintain comprehensive information about patient demographics, current and past Vitals, Illnesses, Allergies, Diagnosis, Medications, Past Encounters, Lab Results, Radiology Results, Notes and Reports, Attached Documents etc. Up-to-date information is available at the click of a button.
• Patient Treatment Summary with Attractive Dashboards.
Mediware EMR electronically porting patient data across different electronic medical records systems. Eliminates the hassle of Physical Transportation or Faxing.
• Electronically storing data requires very little storage space compared to paper records.
• Effective Cost Savings on paper and storage.
• If EMR hosted and open with a domain will provides anytime anywhere access to patient data. Enables physicians to have encounter over phone.
• It does not require expensive machine for clients. A html5 enabled browser in any Operating System can access Mediware EMR.
5. Health Information System (Mediware):
PROJECT MANAGEMENT:
1. Revenue Cycle Management (Planet Group of Pharmacies (Abu Dhabi & GDC Hospital (Abu Dhabi))
2.eClaim:
Supervisor for eclaim solutions for healthcare providers, payers and authorities.
Providers; hospitals, clinics, labs and pharmacies use the systems to prepare and manage e-
claim submissions and resubmissions and manage remittance advices. In addition,
authorization solutions are provided.
Payers; insurance companies and third parties administrators (TPA) are offered dynamic
solutions that allow them to deal with submissions uploads and analysis in addition to
generating resubmissions. The e-claim solutions can be integrated with existing providers and
payers systems.
Authorities; use validation and analytical tools and post office tools to organize, manage and
analyze the electronic claims.
3. Pharmacy Benefit Management (PBM): • eAuthorization request training for providers.
• Online support to providers for any technical related issues to the system.
• Clarrify the clients with Claims benefit related queries.
• Manage to provide technical assistant to clients (Payers / TPA) for system.
• Differentiate between user and technical issues to be escalated.
• 24/7 supporting clients
• Assist technical team in understanding the technical issues inside the system by providing platform.
• Assit technical team in updating Database for drugs (HAAD and DDC), clinicians, and ICD codes for diagnosis (ICD9 for Abu Dhabi and ICD10 Dubai)
• Manage etickets in system reported by providers and close after fixing the issues.
• Manage 24/7 call center for PBMlink support for providers as well clients.
4. Health Information Systems
RESPONIBILITIES:
• Supervise the call centre activities for technical support for the systems.
• Manage the call centre shifts to run 24/7 technical support.
• Assist technical team is understanding technical issues and provide the platform.
• Assit technical team to update database for public (ICD10 release, CPT, HCPCS, DDC, Payers, Selfpaid, Denial codes)
• Generate the tickets in bugs tracking system (JIRA) for the technical issue and send to IT technical team and test successfully after the issue is fixed.
• Manage the trainings for providers like Hospital, Medical centres, Pharmacies.
• Manage the payer system related technical issues and run test successfully.
• Provide the full system training before the implementation of the system.
• Run the test scenarios to make sure the system transaction are running smoothly.
• Manage electronic data on FTP servers for Backups.
• Maintain the standards of the quality for international accreditation.
• Response back to the tickets created by the clients on bug tracking system.
• Train the call centre staff for the efficient knowledge to be provided to clients.
• Support IT Department in designing systems and provide detail report and assistance in recognizing the bugs.
• Make sure to run medical coding guidelines on system for claim edits (Based on CEED).
• Train the clients for editing tools for claim parsing.
• Train the payers for payers system for claim parsing with editing tools and generating remittance advice.
• Manage eclaimlink parser training for clients to make them understand the medical necessity issues.
• Assist technical team to enhance the quality of the system with improvement of functionalities.
• Manage trainings for Clearing House for providers who don’t have resubmission modules in their own system to clear their rejections.
Electronic claims management for insurance.
Very good knowledge of medical coding.
Submission and resubmission of claims to medical insurance companies.
Validate eclaims management with new upgrade as per HAAD circulars.
Process remittance for rejections.
EMR (Electronic Medical Record Management)
Manage daily front desk operations.
Support training in assigned Applications and Clinical workflow processes.
Managing front office.
Patient service management.
Medical insurance management.
Trouble shoots office systems.
Provide implementation and Post Implementation application Support.
Co ordinate and support validation and testing of Application builds, system updates and future processes.
Participate in user training Activities.
Trouble shoots office networking.
TQM (Total Quality Management).
Supports manager in key decision, training of staff.
Assists in developing long-term investment strategies.
Maintains accuracy in accountancy.
Participates in the posting, balancing and reconciliation of the general ledger and subsidiary accounts.
Examines all accounting transactions to ensure accuracy.
Assists in the preparation, analysis and review of estimated revenues, reimbursements, expenditures, fund balances or other proprietary and budgetary accounts.
Researches and analyzes transactions to resolve problems.
Assists in the preparation of annual financial reports.
Recommends or implements changes in accounting and auditing systems and procedures.
Managing financial statements for the monthly invoices to insurances
Monitors current activities for compliance with the country's activities and department goals.
Maintains detailed documentation of audit findings and procedures through the use of papers and audit files.
Assists in monitoring various accounts, verifying availability of funds and classification of expenditures
Making purchase order for disposables and require medical equipment.
Train subordinates to follow proper daily operations.
Coordinate between patient and insurance for the approvals.
Ensuring patient care with safety policies.
E-claims management.
Making credit invoices for insurance companies after administration of medical services.
Infection control programmes.
Providing medical benefits to corporate client (ADIA Abu Dhabi Investment Authority).
Coordinating administration activities.
Maintaining records for expiry and renewal for provider license
Renewing contracts with medical insurance companies.
Motivating team to achieve the organizational objectives and goals.
Managing corporate communication.
Renewing licenses for doctors, nurse and other medical staff.
Maintaining quality standards for medical records and other documentation.
Very well known of HIS (Hospital Information system).
Providing necessary information to the patient about the medical insurance policy.
Taking approvals for the procedure to administer the medical benefits.
Very well known of medical terminology.
1. HIFCON2004 – AIIMS (All India Institute of Medical Sciences) New Delhi, India. 2. GRACE 2005 – AFMC (Armed Force Medical College), Pane, India 3. Human Resource Management in Healthcare: An Emerging Perspective -owaisi Hospital, Hyderabad, India.