REGIONAL COUNTER FRAUD MANAGER-HEALTHCARE:
axa insurance gulf
مجموع سنوات الخبرة :9 years, 0 أشهر
Implement fraud Policy & strategy in Gulf Region.
Plan & Lead Counter-fraud campaigns each year in the Gulf Region.
Investigate cases of potential fraud and abuse, including data analysis and document review.
Interviews suspects, witnesses and analyze their testimony to determine allegations.
Prepare clear concise investigatory memoranda to support findings regarding potential fraud, waste or abuse.
Auditing of healthcare medical providers, Analyze findings, claims experience & financial records.
Arrange comprehensive, factual auditing reports of all investigative activities, all evidence gathering.
Present findings regarding overpayments to providers and/or their attorneys.
Collaborate with Fraud legalizations in AXA PPP & MEDLA Region to strategize on case development, presentation of findings to providers and pursuit of legal remedies.
Manage cases for referral to law enforcement officials for criminal prosecution or to the relevant licensing boards.
Coordinate with medical platforms and country Fraud officer’s representatives in Gulf Region to implement & monitor Fraud strategic plans.
Provide Counter-fraud training as needed to both internal and external parties.
Additional Tasks
Closed File Review and internal audit for internal healthcare claims.
Responsible of process review and setting new blueprints for each process within the medical department.
Review and prepare medical Guidelines and manuals for the three medical platforms.
Manage the relationship between AXA Gulf and AXA ABS India in regards to off shoring process review, pricing models and implementation of corrective action plans to enhance productivity and efficiency of medical claims handling.
Managing provider online portal projects for the pre approval department.
Manage relations with the Medical Providers, which includes management of all the discounts, studying all the price lists, handling reconciliations and visit the Medical Providers on a regular basis, Implements dashboards related to network management and Negotiates in coordination with Regional Insurance Procurement Manager additional discounts wherever possible.
Manage In-patient claims (this supervision includes visits to the patients during their hospitalization) to insure that the services provided are as per our expectations and assure that all medical information is kept confidential.
Manages international cases inbound and outbound to/from Qatar & Arranging evacuation and repatriation for all medical cases through coordination with IEMA, AXA PPP UK & AXA Assistance
Visits medical providers on regular basis to insure proper understanding of AXA guidelines and medical policies, giving reorientation sessions on regular basis to existing providers, Investigates client’s complaints against providers and take necessary steps to promptly resolve the matter & Assists and follow up with prior approval requests
Manages medical team performance of locally based employees, inspection of their overall performance and reporting to Regional Operational Manager & Country Manager
Answers customer and branch staff inquiries concerning cover and exclusions Assist on the medical travel insurance team
Managing relation between Al Koot & AXA in all levels,
Medical presentations for all new potential groups quoting for medical insurance in addition to reorientation presentation to existing medical accounts.
To minimize conflicts with Medical Providers (to make sure that we respect contractual time frames set in the Direct Billing Agreements, to anticipate litigious claims, etc.)
To visit all Medical Providers in the region or country Giving presentation to any new provider
Dealing with prior approvals in an efficient way to insure that appropriate medical care is given at a reasonable cost and that medical care is covered by the medical policy.
Contacting medical providers and customers wherever necessary to obtain information and process claims.
Checking and validation of processed claims before issuing payment.
Updating patients and customers about prior approvals.
Follow up admissions and visit inpatients from time to time.
Supporting customer service staff in assessing high value claims.
Registering and documenting prior approvals requests in the system.
Dispensing medical training to claim processing and customer service staff.
Answering prior approvals within one hour from receipt of approval request.
Responding to telephone queries, responding to written queries within 24 hours.
Keeping all files confidential.
Dealing with network providers in Gulf Area.
Arranging Direct Billing admissions with AXA PPP and international providers.
To handle relations with Medical Providers which includes:
Acknowledging receipt of medical claims sent by Medical Providers;
Dispatching medical claims to medical claim department;
Receiving processed medical claims from medical claim department;
Dispatching payment to medical providers
Handling reconciliation;
Visiting medical providers on regular basis to insure a proper understanding by receptionists, insurance coordinators and doctors of AXA guidelines and medical policies;
Collecting medical reports when required by medical claim department
Visiting and supervising all in-patient cases to insure that the service provided is as per our expectations
Negotiate in coordination with Head of Network Relation additional discounts wherever possible
Insure that Medical Providers have always enough claim form.
To screen reimbursement claims received by the branch before forwarding to the medical claim department to insure that claims submission are complete for claim processing
To insure that the dispatch of reimbursement payment is recorded properly
To answer client and branch staff inquiries in regards to cover and exclusions
Assist and follow up with prior approval requests
Key accountabilities:
To minimize conflicts with Medical Providers (to make sure that we respect contractual time frames set in the Direct Billing Agreements, to anticipate litigious claims, etc.)
To visit all Medical Providers in your region or country at least between 6 to 12 times a year depending on the volume of cases treated by them
To assist clients with their claims submission and prior approval procedures
To keep all files confidential
General examination and treatment of patients suffering different medical complaints.
Preparing outpatients for the consultant’s final diagnosis and treatment for the cases needed specialist advice.
Counseling patients on examination producers, treatments and medication they will have to go throw.
Responsible for surgical patients preoperative and intra-operative assistance in major operations (e.g. open cholecystectomy), doing minor surgical interventions like Herniotomy and circumcision.
Following up postoperative patients.
Issuing health insurance documents for patients and auditing with insurance companies.
Member of infection control team with supervision the policies are followed by our staff.
Issuing health insurance supporting documents for patients’ medical insurance purposes.
ER (Emergency Room) head of the department doctor, handling and following up postoperative inpatients.
Making monthly rosters for doctors in ER and recruiting new doctors for work.
Assisting in Breast Augmentation, Breast Reduction, Liposuction, Abdominoplasty, Rhinoplasty and other minor plastic interventions.
Issuing health insurance supporting documents for patient’s medical insurance purposes.
Completed full levels on practical training rotation program on different sections, such as General Medicine, General Surgery, Gynecology & obstetrics, Anesthesia & Emergency, Pediatrics, Plastic Surgery, and Physical Medicine.
Assistant in Caesarian sections, normal vaginal deliveries, Laparoscopic Cholecystectomy, Hemorrhoidectomy, Herniotomy, Hand Surgery, Liposuction and Hysterectomy operations.
Follow up inpatients on their prescribed medication and other treatments.
Follow up chronic patients in outpatient’s clinics.
Handling emergency cases in the ER departments and assist resident doctors on need.