Manager -Medical Claims
MedNet
Total years of experience :19 years, 0 Months
Presently working as Manager in the medical claim department.
Manging claims operations, maintaining turn around time as per SLA, quaquality assurance, claims reconciliations and audit.
Aug 2007-July 2013 Managed care unit-
- Responsible for Claims authorization, call center management, claims auditing, Fraud and abuse management.
- Planning and managing the Wellness Program and its implementation, including presentations to corporate clients, organization of Health Assessment sessions, conducting seminars on topics like lifestyle diseases as a part of disease management programs.
- Analyzing old claims data for risk assessment to minimize claims loss in future for renewal policies.
-Resolving grievances promptly and maintaining excellent relationships with hospitals, Insured member's and Participating Insurance Companies.
-Coordinating and monitoring the claims process flow and settlements, approving high value claims and ensuring that clients are served with hasslefree claim settlements and cashless approvals not only in UAE but across the globe.
- Administering claims through proactive assessment and management of individual claims, monitoring the claims process including logistics and process control, reporting on registered claims and claims reserve details to senior management.
-Monitoring claims settlements TATs and maintaining the settlement within stipulated time frame.
-Handling claims analysis for cost control, regular revisions and audit on TPA, estimation of reserved reports, and reconciliation of outstanding provider / corporate claims.
-Fraud and Abuse claims control measures, conducting surveys for cashless admissions, coordinating with hospital authorities and medical teams to ensure genuineness of claim/admission, conducting random surveys to spot fraudulent medical reimbursement claims, deputing medical professional surveyors to investigate claims.
-Managing Medical call center 24 x 7, monitoring call center metrics with in Service level agreements.
-Monitoring output of + 15 team members including medical doctor and paramedics at individual levels.
Reimbursement claims-Medical Claims Evaluation and retrospective Audit.
Worked as General practitioner after completion of one year rotatory internship in multi speciality Hospital.
Studied MBBS at Intenational Medical and Technological University Dare Salam Tanzania year . -Rotatory internship in all departments of medicine and Surgery year 2004.