Senior Medical Officer
mednet
مجموع سنوات الخبرة :11 years, 9 أشهر
Provide efficient application of the network utilization review services (mednext) which evaluate and ensure the efficient use of health care resources within the parameters of the MEDICAL INSURANCE policy and other criteria such as appropriateness, quality, necessity, cost, etc… Provide effective, well plan managed care which provides maximum support to the Insurance Company and the Insured, based on the conditions of the insurance policy and the philosophy and guiding principles of the MedNet concept. Implement and maintain a quality assurance program, which evaluates and provides for the improvement of division service, knowledge and competence.
Organization: MedNet Insurance Co. Ltd, Jeddah, K.S.A.
Period: April 2003 - Till date
Designation: Senior Medical Officer
Job Responsibilities:-
➢ Provide efficient application of the network utilization review services (mednext) which evaluate and ensure the efficient use of health care resources within the parameters of the medical insurance policy and other criteria such as appropriateness, quality, necessity, cost, etc
➢ Provide effective, well plan managed care which provides maximum support to the Insurance Company and the Insured, based on the conditions of the insurance policy and the philosophy and guiding principles of the MedNet concept.
➢ Implement and maintain a quality assurance program, which evaluates and provides for the improvement of division service, knowledge and competence.
➢ Checking the following documents to be approved for submitted claims. A standard complete Medical Expense form supplied by the Medical Insurance Company.
➢ Pharmacy bill, detailing drugs and cost of each prescribed drugs.
➢ Diagnostic investigations (laboratory investigation, x-ray etc., ) reports and invoices.
➢ Inpatient hospital detailed invoices.
➢ Checking the approval claim form matching with the insured person I.D card no. Company policy code no.
➢ Sorting out the amount to the concerned department, to maintain the actual discounted amount for the both in-patient and outpatient as per the amount charged in the invoices, as per the procedure done.
➢ Receiving the claims from inured firms, appointed hospital, direct claims from the and outside the country analyzing and doing settlement them.
➢ Checking all the required documents are available or not to process the claim.
➢ Sorting the amount as invoices shows the charges taken for the concerns once in order to get the correct discount.
➢ Deducting the amount for the Co-insurance policies as agreement.
➢ In case of emergency approval are issuing under the policy terms / conditions for the requested subject.
➢ Processing, advising, setting, the claims till to payment computation finally submitting to the manager for reimbursement.
➢ Processed and settled claims records are submitting to the manager for the final settlement.
➢ Doctors Medical Reports.
➢ Checking the schedule of Benefits & Limitations as policy agreed.
➢ Maximum benefit per person per year.
➢ Deductible or co-insurance (In-patient & outpatient)
➢ Room and board sub-limits, physician consultation fees, Surgeon fees, Maternity, Vision benefit & Dental benefits.
➢ Further confirming that there are no more medical invoices that remaining unsettled or disputed for the above period. If any claim which is in-eligible returning them with the note of valid reason.
➢ In case of exceed the amount preparing a debit note to the concern company claiming for the payment.
➢ Checking benefit and its limit & standard exclusions as per policy agreement (dental, optical, maternity, physiotherapy, chronic, and chronic pre-excising)
➢ Check the sub- limit of Dental, optical, physiotherapy and maternity.
➢ Standard Exclusions (cosmetic items, congenital decease etc., )
➢ Check the UCAF whether it is nominated provider to the policy or not.
➢ Check the Category whether it is fit to the provider or not.
➢ Check the batch (provider name and policy name)
➢ Count all claims and check each claim according to the statement of account.
➢ Inform the providers if any missing of claims.
➢ Separation of batch according to the in-patient and out patient.
In view of above, I request you to be kind enough to give me an opportunity to give your esteemed organization the capacity mentioned above for which act of kindness I shall be very thankful to you.
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Provide efficient application of the network utilization review services (mednext) which evaluate and ensure the efficient use of health care resources within the parameters of the medical insurance policy and other criteria such as appropriateness, quality, necessity, cost, etc… Provide effective, well plan managed care which provides maximum support to the Insurance Company and the Insured, based on the conditions of the insurance policy and the philosophy and guiding principles of the MedNet concept. Implement and maintain a quality assurance program, which evaluates and provides for the improvement of division service, knowledge and competence.
Graduate in Bachelor of Commerce (B.com) Osmania University, Hyd, India.
B.Com(Bachelor Of Commerce) from Osmania University. • Intermediate Little flower Junior College, Hyd, India. • Secondary School Certificate (SSC) Hyd, India.