Manager Charge Capture & CDM - PFS
Cleveland Clinic Abu Dhabi
Total years of experience :15 years, 8 Months
Cleveland Clinic Abu Dhabi Accomplishment: -
Charge Capture & Charge Description Master Manager - CCAD Hospitals -Abu Dhabi & AL AIN
Clinical Coding, Charge review, Physician Feedback & E&M Education, CBRS Training, OP Documentation
Improvement & Charge capture activities for both Clinical /Institute Operations & Budget purposes.
Team Strength: - 25 Full Time Code Based Reimbursement Specialist.
•Responsible for day-to-day OP encounters operations and planning for completion of Coding Work queues
•Directed healthcare revenue cycle for Ambulatory services Documentation review, Clinical charge Capture, Coding, Physician Query &
Physician’s feedback, and its Reporting initiatives in Tableau.
•Partnered with the Finance directors and administrators to provide effective revenue categorization & reporting.
•Reviewed the CBRS & CDM team productivity & Performance for all full time & outsourced caregivers for continuous improvement and
Benchmarking.
•Worked jointly with Clinical teams on the improvement of Charge capture projects to align with best practice models, DOH Claim
Compliance, and improve revenue efficiencies.
•Completed the DOH- Comprehensive Screening - Revised DoH Weqaya Program Business & Operational Requirement for IT
implementation.
•Managed implementation and integration of ICD10 /CPT 2018 EPIC roll out and part of IT Contact support Centre Go live July 2021.
•Participated in the Bimonthly Institute Business review -Finance meeting for Outpatient Physician E&M Review updates.
•Epic CDM with DOH tariff /new codes and provide Institute updates for Documentation & Charge capture compliance.
•Reduced the Claim Submission time frame/AR by optimizing the EPIC SVC logic functionality.
•Working jointly with the Research Administrators & Finance Budget team for identifying the revenue prospects for Research Oriented
Service lines and Coordination of Care.
•Works closely with CCAD Laboratory Contracts Manager for all Send-out, Genetic, Anatomic Pathology & Clinical Pathology build
requests along with EPIC/Cerner Order mapping requests
•Optimized the EPIC Coding & Claim Edit functionality for tackling the OP denials as Denial Mitigation Projects.
•Strengthened the relationships & operational efficiencies with all Internal Stakeholders by routine/follow-up biweekly meeting.
•Implemented monthly “Focused Audit” for every services-Inventory Control & Patient Charge Revenue Attributes.
•Prioritized on Claim submission of Tele Medicine encounters during the Pandemic Situation by performing Impact Costing analysis.
•Implemented the workflow and PnP ‘s for Charge Description Master function with Internal controls /audit feedback & Optimization.
•Weekly review & Prioritization of the IT projects based on Impact Analysis with continuous improvement based on regulatory updates.
•Continuous Participation in the DOH Jawda -Tasneef Audit since 2017 till current FY and achieved 95% & 98% Audit score for both CCAD
Abu Dhabi & CCAD AL AIN.
•Served as Audit Representative for Continuous Improvement of Charge capture & CDM-Internal Audit & Financial Audit.
•Served as Revenue SME between EPIC Application team, Finance & Clinical Operations for all Ambulatory Charge Capture Projects
•Leveraged the OP Coding Function to accommodate the patient volumes by 90% with Smart Sets & Scenario based Auto Coding
Functionality.
•Served as Charge Capture SME in the requisition, validation & implementation of the National reference Lab (NRL) -Cerner- Sunquest
Integration Project.
• Completed the Radiation Oncology Charge Capture Processes for Budgeting Purposes for the upcoming CCAD Oncology Project.
•Other Administrative responsibilities include Timecard approval, function related reimbursements, Team engagement, training, and
Individual Professional development for the “Graduate Trainee” UAE National (5 caregivers). Interview the HC short listed candidates
for Full-Time Hires and on boarding hiring manager responsibilities.
Audit medical, surgical insurance claims prior to Claim submissions.
Coordinating and practicing the (Dubai Health Authority) regulations and proactively implementing the same in billing & Eclaims submission.
Visiting the In-house providers (physicians, surgeons) EHR module and checking their quality and inspecting the patient record randomly.
Training the front desk officers, Call Centre Agent on the insurance & admission protocols.
Handling the IP cashiers in terms of medical claims billing and claiming services as per agreed tariffs and policies.
Handling queries from insurances and with respect to their high volume claims and escalating to the insurance manager for volume discounts.
Coordinating with the Doctors and Pricing Committee for adding new and advanced procedures.
Mapping the internal codes with CPT and escalating to the Networks for inclusions.
Suggesting/implement new policies-audit systems for CSH.
Assist JCIA Quality Unit on reporting and documentation of medical records.
Monthly submission of Insurance Audit reports to the Insurance Manager & Quality Director as per Dubai Health Authority (DHA) regulations-reviewing the claims based on standard coding guidelines and note any discrepancies in terms of malpractice, fraudulence & abuse
Exporting and mapping the internal tariff to the CPT/HCPCS/DDC/DSL codes to facilitate the insurance claims submission process.
Play a major role to minimize rejection by reviewing the remittances advices/explanation of benefits/credit note and Reconciliation of medically eligible claims.
Maintaining insurance wise submission checklist enabling better controls and checkpoints.
Heading the In-patient Insurance department, handling the admissions of Elective & ER cases, & Submissions.
Coding high volume cases with respect to the coding guidelines in terms of diagnosis.
Play a major role in enabling the smooth flow of Revenue cycle and contribute suggestions to minimize errors.
Conducting in house training sessions in Electronic health record-Insurance module for physicians, surgeons, & Allied health care assistants.
Managing the national and international policies & claims.
Making proposals and projects for the company.
Managing and monitoring the team on all network activities.
Associate with the Sales team on medical underwriting
Coordinate with the payers (Insurance companies) on various issues, new policies and assisting them in giving the feedback on utilization based on providers tariffs.
Coordinates with brokers, update them the network updates etc
Assists the BD Team on various utilization data reports.
Updating the TOBs to the TPA and explaining the policy benefits in detail.
Verifying the claim history prior to quotation process and calculating the expected cost for high risk members for group policies.
Attending to brokers, TPA and insured escalated queries on pre-authorization, re-imbursement and medical assessment.
Verification of the claim history and calculation of Loss Ratio for retention of corporate policy holders.
Final Approval of claims and authorization of payments.
Review of medical claims (above AED 40, 000) processed by the Third party administrator.
Raising the issues/problem areas to the management, for claims erroneously paid by the TPA.
Documentation of claims above a certain limit and forwarding to the re-insurer for approval.
Assist in business reports for claims & controlling and performance tracking for the medical team at ESDB.
Maintaining effective Customer service by explaining the TOB to clients thus ensuring satisfaction, transparency & retention.
Maintain effective relationship with external and internal customers. (Insurance Brokers, Helpline, Claims, Client services, I.T, Insurance Providers & Coordinators, Medical Practitioners, Insured Members, Sales, Admin, Operations, Accounts.)
Termination of policy in case of any misrepresentation of facts on medical grounds.
Addressing, Recommending and correcting the gaps in insurance policies/products.