- First Name - أحمد

Managing medical claims end to end providing the highest level of health care in a competative fashion, leading the team with focus on performance and quality improvement.Strategic planning ensuring incorporation within the operational plan of the company

• Managing Medical Insurance related Issues.
• Contracting with the medical insurance companies.
• Contracting with private companies for in-house management of their employees.
• Daily management of claims and claims error reports with significant Improvement in the claims rejection rates
. Ensuring payment of all claims and keeping abreast of reimbursement issues associated with assigned payers
• Coordinating patient-focused care in a cost-effective manner without diminishing the quality of care a patient receives regardless of age.
• Using medical expertise to offer alternative means of care to patients determined to be in need either because they are about to be discharged or require long-term care that is sensitive to the center's budgetary requirements.
• Advocating on behalf of the patients while working directly with the management and physicians to determine the best course of action while communicating available high-quality resources to the patient
. Integrating within the medical center’s operational plan with a focus on high quality customer service and respect to medical & work ethics at all times
• Ensuring insight in medical costs and quality/efficiency of medical insurance processes by supplementary data analysis and advise on suitable improvement initiatives and ensure that the management supports them
• Developing and monitoring skills to fulfill the tasks requirements according to operational performance indicators of the medical center.
• Managing the internal administrative affairs of the Medical Center including recruitment of medical staff

• Organized workload between employees in order to accomplish the Claims Processing Department’s mission within agreed quality standards
• Developed provider Network by Contracting, negotiating and agreeing on competitive prices with the providers.
• Maintained relationships with providers and negotiated financially advantageous contractual arrangements with implementation of standard contractual terms and conditions, up to signing of agreements while assuring the compliance of regulations & the delivery of business benefits.
• Maintained the providers’ network & ranked them according to their unit cost, practice type, & geographical distribution to allow the sales team to allocate members to the appropriate providers group.
• Planned, coordinated & carried regular visits to the providers in order to maintain with them professional relationship
• Improved agreements of existing providers by negotiating and signing up better prices & discounts to guarantee that the company will achieve the price reduction targets set on annual basis
• Established good relationship with new providers
• Followed up by phone & with written correspondences on issues raised during negotiation with providers
• Had regular liaison with network providers to resolve issues and complaints of the customers that were received through customer service and sales units and maintained a log of complaints against providers
• Recorded and maintained all medical provider details in the region onto the provider database in the company
• Held regular appraisal with medical service providers to update information and solicit feedback on their service delivery.
• Contributed towards the development of a system for measuring service provider’s performance, both in terms of quality of service as well as in cost efficiency
• Developed system for In House Claims Processing Department
• Was wholly accountable for the medical department with a strong liaison with the TPA

Was wholly accountable for the medical department with a strong liaison with the TPA
• Implemented approved Insurance plans & coverage, ensuring savings on premiums & marked improvement in the quality of service provided by the company.
•Processed all insurance claims ensuring that documents are complete & arranged prompt settlement of claims. Followed up on pending issues & disputes of different kinds.
•Managed high value & prestigious claims/ accounts billed by hospitals
•Finalized hospital Contracts, ensuring that all providers operate company’s contractual and medical procedures effectively through effective training & regular visits
•Finalized reconciliation of the monthly budgetary report " monthly account signoff” s for insurance premiums & offered explanations for any variations with positive outcome that contributes to the overall loss ratio
•Participated in the development of Claims & Pre-approval electronic management system.
•Promptly recognized & met with the changing requirements of existing Clients while demonstrating excellent service levels to all valued Clients.
•Answered day-to-day operational queries from customers on medical service related issues with highest level of empathy for customer situation
•Used automated information systems to analyze the customers situation
•Reduced call abandonment rate from over 4% to less than 1%.Reviewed recorded calls with CSRs to ensure quality .
•Had regular Liaise with Reinsurers, Hospitals, Pharmacies, Clients & kept the management posted with all major events in a timely manner.
•Prepared various statistics, management information reports.
•.Reported overpayments, underpayments & other irregularities periodically to VP
. Ensured that claims processing is in accordance with the regional legal counsel requirements
. Managed & monitored various In-house Clinics, Pricelist Issues, Reimbursement Affairs
.•Kept up to date information on emerging trends in the market.

• Developed Medical Guidelines for the nursing and pharmaceutical staff to enable them evaluate the medical claims received from the hospitals thus cutting the cost of the claims management.
• Medically classified and adjudicated all High value In-patients claims in the context of their appropriate investigations and medical management.
• Took Judgment and decision regarding the clinical appropriateness of billed treatment calculating shortfall for each line item which is believed to be inappropriate.
• Ensured regular quality checking of claims adjudicated and inputted on the system on daily basis and feedback to the concerned team members.
• Enhanced Claims process refinement
• Made regular Presentations, training sessions to other medical officers of the team
• Replied and soothed customer enquiries and grievances
• Had regular interaction with the hospitals regarding approvals and reconciliation
• Finally managed the medical team
• Developed Medical Guidelines for the nursing and pharmaceutical staff to enable them evaluate the medical claims received from the hospitals thus cutting the cost of the claims management.