Ibrahim Mustafa Ibrahim Suliman

-Provider Recruitment: Identify, recruit, and on board new healthcare providers into the network, including physicians, hospitals, clinics, and specialty care providers.
-Contract Negotiations: Negotiate provider contracts, ensuring compliance with healthcare regulations, fee schedules, and performance metrics.
-Provider Support: Act as a primary point of contact for network providers, addressing inquiries, resolving issues, and providing ongoing support.
-Compliance & Credentialing: Ensure providers meet the necessary credentialing, licensing, and regulatory requirements to be part of the network.
-Network Performance Monitoring: Monitor the performance and quality of care provided by network providers. Collaborate with providers to ensure they meet or exceed performance standards and guidelines.
-Data Management & Reporting: Maintain accurate provider data in the system and prepare regular reports on network performance, provider satisfaction, and utilization.
-Staying informed about changes in healthcare laws and regulations.
Ensuring that provider network operations comply with all relevant legal and regulatory requirements.
Preparing for and participating in regulatory audits and reviews.
-Contributing to the development and implementation of the company’s provider network strategy.
Identifying and pursuing opportunities for network expansion and enhancement.
-Providing training and resources to help providers understand and comply with company policies and procedures.

- Oversee Revenue Cycle Dept. END to END, Contract, Eligibility, Approvals, Billing, Audit, Coding, submission, Resubmission & Reconciliation,
- Analyze, develop policies related to health care system, work flow and regulations,
- Ensuring compliance with Health care regulations or coverage and improving the financial performance, by Audit Bills and Claims for INPATIENT, DAYCASE & OUTPATIENT cases,
- Oversee patient financial services representatives (PSFR), for any unclear or discrepancies charging or coverage, handle and provide solution to enhance revenue cycle,
- Analyzing and developing medical services and procedure pricing and costing strategies to optimize healthcare delivery and financial performance,
- Conduct in depth analysis of health data and statistics to identify trends, support operational strategies and align health outcomes with financial performance goals,
- Monitor Revenue Cycle metrics, Account receivable, Net Collection, Clean Claim Rate & Claims Aging,
- Work Closely with other Dept. such as clinical staff, to ensue seamless operation and solve any issue that may affect revenue cycle efficiency,
- Ensure positive patient experience by addressing and solve any billing or insurance related questions or concerns and empathy in patients and family’s interaction,
- Assist patients and families with financial matters including insurance coverage, limit, Billing, exclusions - out of pocket, pending approvals, or additional information from clinical staff,
- Oversee payer and insurance portals, payments, add, Cancel Doctors & add or cancel services,
- Prepare and Analyze Regular Reports & statistics, escalate critical issues to High Management,
- Manage Health insurance benefit plan for our staff and families, get quotation and make comparisons, Recommendation, evaluate policy and coverage plan & follow in Add and cancel,
- Good relation with key persons across health care providers and Health Insurance Companies in a region,
- Liaise with MOPH and attend workshop according new health insurance scheme, coding & Mapping.
- Monitor and prepare KPI in insurance Dept. (Claims processing time, Denial Rate, patient satisfaction, Claims cost, first time approval rate etc.) escalate critical to the Quality & management,
- Manage and Coach the team & performance evaluation,

- Revenue cycle management - End to End for Five Branches with Pharmacies
(Contract management & Policies - eligibility - Approvals - Medical Billing- Audit- Coding- claims Submission- Manage Credit Account & Follow Payment- Resubmission, Reconciliation & Closing).
- Oversee Operational Daily work for insurance, Approvals, HCIT, billing and claims Dept.
- Monitor and Identifies any Revenue Cycle gaps or loss,
- Design, update and implements policies, pricing Model, procedures and protocol to ensure efficiency and accuracy (Medical & Finance)
- Supervise ERP System (Medical Billing) implementation with new criteria as needed, from IT external vendor for RCM Dept.
- Develop, Negotiate and maintain contracts and policies with payers, insurance, TPA & Government program,
- Review and Monitor Medical reports and cases before submit to delegate authorization, as health compliance and Guidelines,
-Submit claims to Insurance Co. as guidelines on time. Good relation with most of healthcare providers and payers,
- Manage and Train Medical Coding Team, ICD9. ICD10 CM & AM, CPT and DRG.
-Audit and process medical claims, Monitor fraud, waste and abuse, medically & technically depend on Good medical practice, medical items and consumables,
- Liaise with MOPH According a new National Health insurance scheme,
- Attend Meeting and prepare presentation for Insurance Staff, Doctors & other Depts.
- Project management tools and handling budget
- Create Insurance KPIs to measure performance and success,
-Identify Trends and patterns in Claims Errors and propose strategies to prevent future issues,
- Good relations with Health care providers and payers (Insurance Co. & TPA), to follow and update guidelines and payment allocations,
- Analyze and review current and new policy to ensure adhere to all laws and regulations, Monitor compliance the risks,
- Pricing, analyze benchmarks, claims cost, Discounts (contractual, Volume & Annual)
- Prepare and present initiative (How to deal with insurance patients, Zero Rejections initiative & Fraud manipulation)
-Manage some Clinical program, international SOS, Swimming champion, sport day event, & covid19 PCR for Ministry of defense project
- Hire and train new staff, performance evaluation and coach staff,

Managing two branches

-Maintain up-to-date billing and invoicing system
-updating policies and discounts rates.
-Responsible for daily generation and consolidation of invoices.
-Auditing E-Claims invoices and assuring zero rejections.
-Checking CPT code, approval code, approval validity, card number and dates of invoices.
-Follow-up with Laboratory, Radiology, Cashier and Admission department for any pending invoices.
-Co-ordination with I.T. for raising the E-claims files and generation of CTR.
- Coordinating with coders For correct Billing and ICDs
-Providing Necessary Trainings & support to billing Staff, Receptionist and New Staff.
-Timely reporting of any cause of delay in raising the invoices.
-Follow up collection & allocation of payments.
-Carry out billing, collection and reporting activities according to specific deadlines.
-Re-submission & investigation of rejected claims.
-Coordination with Coding Department & Auditing Department regarding the medical rejection.
-Providing necessary information for obtaining pre authorization

- Review Patients Medical Record to ensure their accuracy, these records are typically coded using standards such as International classification of Disease
- Ensure the Accuracy of claims to accomplish this, the negotiated rates with health care providers are examined, medical plans and the benefits they allow, payments information, eligibility criteria, whether services were performed in network, and the turnaround time of claims - Examining medical records to ensure accuracy of billing and payments
- Examining Cross border Invoices and Medical Records to ensure accuracy of billing and payments
- Making sure the information is accurate and all guidelines have been followed before approving payments.
- Checking Medical supplies, in terms of misuse, up use and related to case or not related.
- Work as Field liaison Officer in Hospitals, to Follow Patients, facilitate their treatments, give medical Approvals, and ensure that all polices are Implemented by hospital with our patients .
- Provide the needed assistance, approvals, and follow up for the adherents on a daily work.
- Handle customers, risk carriers, and provider requests and coordinate with providers to resolve all problems related to our adherents.
- Communicate with Doctors and Nursing to ascertain the treatment plane to be followed with patients
- Take a round of patients in the hospital to confirm and fill in patients' satisfaction, and provide the company of Patients Notes

Validates the information on all medical claims from patients seeking payment from their insurance company, Review the claim to ensure that there is no missing or incomplete information, keep meticulous records of claims and follow up on lapsed cases. Use coded data to produce and submit claims to insurance companies, working directly with the insurance company, healthcare provider, and patient to get a claim processed and paid, Verifying patients’ insurance coverage, Answering patients’ billing questions...
* Health insurance coordinator: Responsible of health insurance contract for hospital staff, Liaison office between the health insurance company and hospital. Participation, add, and cancel Employee staff . Responsible of treatment forms, control and distribution of forms among hospital staff.