Precertification Manager
Saudi NextCare
Total years of experience :21 years, 0 Months
Currently I'm the Precertification Manager at Nextcare KSA, a leading TPA company in MENA region and a member of renowned Allianz Partners, the international leader in insurance and assistance services. My responsibilities include the following:
- Managing, leading and developing a customer-focused result-oriented team (20+) of medical professionals to ensure customers receive professional, attentive care in a timely manner.
- Regular monitoring of Key Performance Indicators including TAT, quantitative and qualitative assessment.
- Monitor the healthcare services utilization patterns of insured members, cost per claim and burning rates with regular analysis of insured members consumption patterns as well as the healthcare providers behavior and efficiency of care.
- Cost containment planing to ensure the most efficient healthcare service use and ensure effective implementation of primary healthcare module and referral protocols.
- Regular communication and reporting to insurance companies regarding cost containment procedures and Key Risk Indicators.
- Communication with the external regulators responding to inquiries and complaints raised related to the pre-authorization or claims department and to ensure that department performance is completely abiding with the regulations and directions of the regulating authorities in the form of TAT and fair customer treatment as well as services coverage limits.
- Participate in the regular strategic committee meetings and take role in the strategic planning for the company. Also contribute in developing, updating and implementing policies and procedures to suit the functional objectives of the business.
- Supervision of the medical claims team including workload distribution and ensuring adequate staffing/resources daily and on a long term basis. Also schedule staff and distribute daily workload, as well as forecast future staffing resources to ensure optimal customer service.
- Manage and supervise Team outputs as well as individual performance to achieve monthly team targets in terms of quantitative and qualitative aspects and maintain the productivity reports of the team members as well as prepare & maintain weekly & monthly reports.
- Suggest training requirements of staff to ensure growth of productivity and enhancement of quality.
• Care Plus (www.careplusegypt.com) is a leading Healthcare company in Egypt working in the felid of providing medical services and healthcare/health insurance management.
• I worked as a site physician providing primary health care service for companies and corporates and supervising the referrals to consultants, laboratories and imaging centres. As a senior medical officer on site my job included approval or concurrence of proposed medical procedures and investigations based on the assessment of the medical condition of the patient.
• I have joined the management team as assistant medical director of the company supervising the preauthorization and registration of medical procedures and investigations proposed to clients and working in liaison with healthcare providers including hospitals, labs and imaging centres to make sure of providing high quality healthcare services meeting the clients satisfaction and to eliminate any fraud acts.
• Monster Transcription (www.monstertranscription.com) is a company specialized in providing medical transcription and operations control services for US-based radiology groups and Teleradiology companies.
• Using my extended experience in Electronic Medical Records (EMR) and Radiology Information Systems (RIS), I built multiple medical transcription teams consisting of medically trained members (physicians, dentists and pharmacists) to provide typing, archiving and QC/QA or medical data dictated by physicians in USA using digital recording devices. We have developed and implemented our own training program including medical terminology, radiological anatomy, English grammar and style and EMR protocols.
• The company is also providing Radiology Operations Control service for multiple radiology groups which includes providing a back office and medical call center services for US-based companies especially after-hours and overnight.
• I was holding that position at Epic Teleradiology "www.epictele.com"
• It is a leading American company working in the field of Teleradiology. All operations were based in Epic Cairo Office and all the company clients are health care facilities in USA including medical centers and hospitals.
• I was responsible for designing and implementing QA protocols for the departments of medical transcription and operations control.
• Also I shared in testing and implementation of a new Teleradiology system (XIRIS), that was built for the company and I was responsible for training of the whole staff including the radiologists, transcriptionists and operation center employees.
joined my residency in Internal Medicine in the Unite of Endocrinology and diabetes in Al-Hussien University Hospital.
During that year I spent two months in the four general specialities: General Medicine, General Surgery, Obstetrics and Gynaecology and Paediatrics. Then I spent one month in Cardiology, Orthopaedics, Anaesthesiology/Critical Care, and Physical Medicine
Certificate in Insurance (Cert. CII) 1. Insurance Legal and Regulatory (IF1): Passed in October 2014. 2. General Insurance Business (IF2): Passed in April, 2015. 3. Healthcare Insurance Products (IF7): Passed in April, 2015. 4. Insurance Law (P05): Passed in October 2015 5.Insurance Business and Finance: Passed test on April 2016.
• Bachelor in Medicine and Surgery (MBBCh) (December 2002). Graduated at the Faculty of Medicine, Al-Azhar University in Cairo, Egypt. Overall grade: Excellent with Honour (89%). Pre-Registration House Officer (2003): • During that year I spent two months in the four general specialities: General Medicine, General Surgery, Obstetrics and Gynaecology and Paediatrics. Then I spent one month in Cardiology, Orthopaedics, Anaesthesiology/Critical Care, and Physical Medicine Senior House Officer in Internal Medicine (2004): • I joined my residency in Internal Medicine in the Unite of Endocrinology and diabetes in Al-Hussien University Hospital.