Mena Emil

Auditor Doctor for Medical Insurance Claims à Med Gulf Health Insurance Co.

• Arabie Saoudite - Riyad
• Je travaille ici depuis septembre 2012

Auditor Doctor as Egyuser-135 "KSA Claims operation Office "Medivisa -member of Medgulf group ( Audit Back Office of EGYPT )

- Auditing, processing and closing of multiple Saudian companies claims since Sept 2012 till present.

- Auditing, processing and closing of SABIC claims since Sept 2012 till present.

• Audits all claims in excess of Claim Examiners payment authority limits

• Authorizes and releases claims in excess of Claim Examiners payment authority limits

• Performs target claim audits as directed

• Checking the Technical aspect of the claim through a lot of things (ex .The policy, limit of the outpatient visit, limit of inpatient visit, validity of insurance policy, the class of the member, covered and not covered services, Deductibles, Immediate approvals and Some services to be debited to the Policy holder according to Policy…etc )

• Checking the Medical aspect of the claim and what can be rejected and what can be paid according to Policy, Benefits, Immediate approvals given to the member and the clinical information given through wide medical knowledge .

• Prepares and distributes monthly audit reports .

• Communicates audit findings with Examiners through comments .

• Reviews claim audit results with Claims Manager on a regular scheduled basis

• Notifies Claims Manager of any training needs identified during routine auditing

• Notifies Claims Manager of any strange Acts within the auditing process from different providers (ex. Excessive medical service, investigations and medications ) or different Policy holders (as requesting not covered services )

• Provides ongoing training to Claims Examiners as identified by auditing process

• Assists with claims processing, claim adjustments and appeals resolution process as needed