MEDICAL CLAIMS SPECILAIST AND PROVIDER RELATIONSHIP
GLOBEMED SAUDI
Total years of experience :15 years, 3 Months
WORK AS A SENIOR APPROVAL DOCTOR AND PROVIDER RELATIONSHIP
Work with many insurance companies in Saudia like (ARABIA &WAFA&SALAMAH &SOLIDARITY&AMANA&WAQIA&AL SAQUR)
Dealing with more than 2 million customers in ksa
And more than 4 millions all over the world
We give more than 1000 daily approvals (inpatient and outpatient)
We use online system for approvals also we do offline approvals for providers that can’t use online system by email or by fax
My rule is to give approvals according to CCHI and company rules .
Also we answer all complains coming to us by call center or comes from CCHI.
We work as a team to give approvals and solving all problems.
Our company a TPA company this give us an experience a bout rules for many insurance companies in ksa
In our company we have two projects one related to Saudi MOH and other related to General Organization for Social Insurance (GOSI) in KSA
Our rules in this project to valid all inpatient visas and audit all claims comes to MOH or to GOSI .
I work as assistant provider relationship for medical fraud.
There is a plan that I will start medical fraud unit
1.Al Hekma hospital (in egypt)
as General Practitioner from 1/1/2010 till 28/2/2010.
See patient complaining from general diseases and simple surgery procedures. Know how to deal with most of simple internal medicine and pediatric and surgery cases .
2.Operation for Health Care company :( medical insurance company in egypt )
start from 1/11/2009 till 30/10/2011.work as claim officer & auditing for 1year. medical approval department for 1 year( 4 months as agent and 8 months as senior and agent trainer .)
in medical approval department :
we deal daily with almost 500 ordinary approvals and more than 20 surgery approvals.
-As a senior for this department I gave many approvals for major operations like open heart surgery and laminectomy surgeries .
-We was dealing with customers from big companies in Egypt like :
Vodafone Egypt …CMA…REDY MEX INTERNATIONAL …Citibank…bank auda…EGYPT POST…PEPSICO EGYPT
Our total customer almost one million customer .
-I was in contact daily with most of hospitals to follow up our patients in this hospitals
Hospitals like
Dar alfouad … al salam international …al nozha hospital … Cleopatra hospital …
Every day I was following all inpatient cases by phone and by direct visits .
In medical auditing department :
We review every medical claims from all providers
Our daily task to review more than 1000 outpatient claims and about 10 inpatient claims .this gives me experience how to know medical Deception or fraud and medical claims errors .
Our rejection rate was over 40 percent .
3.Unicare for health care : (medical insurance company in egypt)
Start from 1/11/2011 till 10/1/2012
Hospital follow up and client medical status determination (roofing).
I had daily tasks to follow up more than 15 inpatient cases and help in daily providers complains or problems .
Every day I almost found about 7 to 10 cases no medical need for them to stay in hospital.
4.DOHA MEDICAL CLINICS (in Al Doha kingdom of saudi arabia ):
Work as head of medical insurance department .claim auditing and medical approval responsible. Claim Reconciliation And provider relationship
Starting from 15/1/2012 till now .
Have valid Iqama and MOH License as General Practitioner.
Im dealing with all insurance companies in KSA like Bupa …
Tawuniya …Medgulf …Saudi nextcare…Globmed
Every day I take more than 50 approvals.
I know most of table of benefits of major insurance companies .
I deal daily with patients from big companies like SABIC …SAUDI TELECOM …ARAMCO…and solves there issues .
Every month I arranges our medical claims for all companies .my aim target to have rejection less than 10 percent .im dealing monthly with about 12000 claims.
I deal daily with all insurance and other credit companies to solve patients issue like lost insurance card or eligibility problems or late approvals .
I explain to patients why some services not approved or not covered … so I am aware to all insurance companies polices …table of benefits and dental .maternity .optical protocols .
Every month. I contact with all insurance companies to follow up my claims and know rate of rejection and finish Reconciliation.
I contact with many companies like Saudi catering … esad ..synopic ..BGP..Delma …as a provider relationship to solve there issues and settle there needs like results of medical checkup for iquma and employer medical checkup and aramco and baladiya medical checkup .
Start my class in august 2002 and finished in December 2009 (7 years). My degree Good with 72 percent . I studied medicine and surgery with one year internship in hospital
