Manager - Medical Pre-approvals/Reimbursement at NEXtCARE - ALLIAZ
NEXtCARE
Total des années d'expérience :20 years, 1 Mois
- Plan, organize and direct the medical claims precertification department.
- Monitor claims activities, performance management, production standards and quality of results.
- Provide technical assistance to supervisory staff to initiate precertification to all appropriate healthcare providers and members.
- Monitor and audit daily performance to ensure the best possible customer service.
Ensure contractual agreements are being met daily.
- Continuously work to identify broken processes; develop, recommend and implement improvements.
- Analyze customer volumes and provide customer service reports to management.
- Manage and develop team of 75+ employees including physicians, dentists, pharmacists and nurses: monitor workload, ensure job proficiency, develop career goals by evaluating and monitoring individual staff performance and giving appropriate feedback, identify training and development needs and support training attendance
- Lead and motivate staff to achieve excellent customer service standards, retain staff and create a good working environment, recognize accomplishments, and serve as role model and coach by providing feedback to improve performance and executing progressive discipline as needed.
- Establish, communicate and manage goals and expectations for the department and individual performance.
- Evaluate medical claims and determine validity of the claims. - Arrange for 2nd opinion consultation for complex/grey area cases. - Collects and validates the data via reporting queries and chart review. - Submit the data to the management and head quarter in a timely manner - Analyzes data against quality indicators using complex standards and protocols according to National and International clinical guidelines - Share in fraud analysis. - Analysis of the medical data of claims, beneficiaries, providers and service levels. - Medical research for new techniques and procedures. - Collect, analyze, interpret, and summarize data in preparation for generation of statistical, analytical, and narrative reports. - Uses clinical knowledge to identify trends related to clinical outcomes. - Design and implement reports and dashboards as per the business needs. -Work with the various business departments as needed to identify and receive needed data elements and resolve data queries and reporting needs - Assist in auditing and preparing reports on auditing activities. - Defined work flow process and Policy Procedures of the units and its effectiveness through system controls - Help set priorities and organize workload to meet the target KPIs. - Follow up and reports status and problems relating to above projects and activities - Assist with data/requirements collection, data organization and project implementation. - Schedule and coordinate meetings, tasks and deliverables - Monitor procedural compliance (i.e., issue tracking, scope management, etc.) - Communicate with and keep relevant stakeholders updated on project status. - Responsible for working closely with the user team and the vendor of HCIS. - Responsible for studying, analyzing, documenting and mapping the process. - Maintain documentation, process flow and charts.
- Directs, supervises and coaches front office and clinical staff daily.
- Managing the flow of the clinic to insure compliance, efficiency and patient satisfaction.
- Problem solving and addressing issues raised by physicians, employees, and patients.
- Managing claims submissions for different insurance companies.
- Reporting Profit and Loss responsibility of the physician practice, including revenue, expenses and budgeting.
- Managing physicians/staff calendar and booking systems.
- Developing and implementing Polyclinic Management System integrated with a tailored CRM.
- Conduct demos and presentations for pre-sales activities
- Designing, Development planning, and Implementing Systems developed by J2EE, PHP .
- Arrange for live demos and pilot projects and presentations in KSA.
- Share in DBA tasks like installing, backup, restore oracle db 10g.
- Writing and preparing for the technical documentations.
- Worked as a General Practitioner at the Cairo University hospital, emergency department.
- Deal with acute emergency cases such as :
• cut wounds
• Acute abdominal pain e.g renal colic .
• Angina Pectoris
• Burns
• Some pediatric cases e.g acute pharyngitis and diarrhea .
- Worked as a 1st assistant with the general surgery consultant at several operations such as :
• Appendectomy.
• Laparoscopic cholecystectomy.
• Herniotomy and hernioraphy.
• Breast mass excision.
• Above and below knee amputation.
• Varicocele.
Bachelor Degree of Medicine & Surgery, Cairo University Grade: Good