مصطفى سالم باتيس

Nature of Job:
 Evaluation of Reimbursement cash claims which received from in or out KSA by applying predetermined policy and procedure from medical and technical aspects.
 Executes a variety of claims administration activities for medium complexity and high complexity reimbursable Medical claims (typically medium to high value as well)
 Identifying, flagging, and investigating fraud cases
 Paying detailed attention to Abuse of services.
 Communicating with the client and explain issues or queries regarding rejection or pending reimbursement claim from medical and technical aspects.
 Answering inquiries received from claimants on the status of medical approvals
 Meeting and discussing with claimants and negotiating a fair settlement with the claimant
 Assessing and recommending the fair value for the claim
 Complaint Management, Follow up the insured members complaint against our TPA services, approval & networking issues
 Follow up TPA works (GlobMed Saudi) regarding to networking, claims and approvals
 Liaising clients and providers compliments at CCHI
 Communicating with CCHI for various queries / complaints including specific queries or claimant complaints.
 policies monitoring with claims performance analysis and follow up
 Update the policyholders with the claims experience and incurred claims losses
 Adjustment of policies premium based on health declaration and claims history

A. Medical Claims Officer : Apr-2011 till Jan-2016
Nature of Job:
 Evaluation of claims by applying predetermined policy and procedure from medical and technical aspects of Direct Network Claims, justifying or rejecting the claimed services in alliance with presented clinical scenario.
 Applying classification of diseases (ICD 10) at Claims.
 Observing over all technical discrepancies in terms of errors, overprices, duplicities, trends, irrelevancies.
 Paying detailed attention to fraud and Abuse of services, reporting upon discovery to company’s fraud committee.
 Maintaining strict adherence to the company’s Policy Procedures, Regulatory Authority’s guidelines, simultaneously keeping in consideration of strategic business liabilities.
 Successfully achieved targets and met deadlines of assigned tasks.
 Achieving Department’s goal on desired rejection level ongoing basis.
 Weekly reporting to department manager with detailed analysis of evaluated batches.
 Handled re-submissions, queries, issues and explanations regarding technical and medical rejections to direct clients or providers.

B. Reimbursement Claims Officer : Apr-2013 till Jan-2016
Nature of Job:
 Receiving cash claims requests from various levels of Providers including Hospitals and Clinics from all over K.S.A and outside K.S.A through policyholder client / customer.
 Evaluation of cash claims by applying predetermined policy and procedure from medical and technical aspects.
 Communicating with the client and explain issues or queries regarding rejection or deferred claim from medical and technical aspects.
 Auditing and Settlement of the claims.


C. Medical Approval Officer : Jan-2014 till Oct-2015
Nature of Job:
 Pre- Authorizing Medical Services requests receiving from various levels of Network Providers including Hospitals and Clinics from all over K.S.A
 Granting of Approval or Denial is solely based on presented clinical background and in accordance with Company’s and regulators (CCHI) polices.
 Replying of requests within assigned time frame whether approved or denied with complete justifications.
 Consulting with Senior Colleagues in case of Complex case scenarios.
 Answering the customer queries based on the necessity.
 Paying detailed attention to fraud and Abuse of services.
 Notifications with analysis upon discovering of abusive and suspicious acts of providers to concerned departments and higher management
 Successfully achieving targets and met deadlines of assigned tasks.