Amber Mehmood Kherani

Metlife Alico - Pakistan: (Financial Services) : April 2008 to date

Assistant Manager - Managed Care Operations: January 1st 2012 till date
Officer - Managed Care operations: March 2nd 2009 - December 31st 2011
Management Trainee: April 22’ 2008 - August 31st 2008

Job Responsibilities:-

• Responsible for the contracting with the healthcare service providers within corporate guidelines to ensure all services provided are in accord with quality standards.
• Negotiates complex contracts with hospital providers & Legal Department with regard to the financial and legal impact of provider contract language requested.
• Managing provider relations efficiently with skilful negotiation of prices keeping an eye on provider KPIs, supporting profitable development and growth of the business and the achievement of overall departmental objectives in line with company’s vision and mission.
• Accumulate Company’s savings by getting volume & fast tract discounts from provider.
• Recommends and develop monthly statistical reports to facilitate benchmarking and performance management of network operations & utilization trends for management decision-making of local & regional offices.
• Oversees the appropriate and timely intervention including, but not limited to, when providers have issues related to bills or claims settlement.
• Perform audit of randomly selected claims to ensure quality processing.
• Attainment of signoff letters from all providers after reunite books of accounts of both parties.
• Update data relating to addresses, discounts, tariffs, service charges, creation of new codes, specialties, etc. as on need basis.
• Dealing with case management, approval, pre authorization & rejections & processing them in company’s database ensuring all information that is supplied is eligible for payments to be made.
• Telephonic investigation / verification of facts involved in the claims & pre-authorization.
• Take statements & consult with claimants, doctors & relevant individuals to examine records.
• Works closely with marketing department regarding group medical policy & renewals.
• Provide clarifications regarding policy wordings to insured & other stake holders.

Special Assignments:-
• Implemented risk rating project under FCPA policy, across the board for all providers.
• Maintain client’s pre-employment/periodic medical records, inform related parties for fitness/re-assessment (if any) & prepare reports for settlement of their bills that falls within & beyond scope of policy.

Accomplishments:-
• Detected potential frauds in claims processing & investigate the procedures.