Health Insurance Portfolio Consultant
Al Sagr Insurance Cooperative Company – Dammam- KSA
Total years of experience :21 years, 5 Months
Operations - Develop, establish and implement Medical Department underwriting, claims, and reinsurance strategies, guidelines, and procedures to achieve maximum long-term profit and growth.
Operations - Support in development and implementation of department strategy according to the company vision, responsible for setting the section’s operational goals, initiate measures, and has accountability in reaching these goals to improve the overall operations performance
Business Management - Responsible for result-oriented management and development of people and resources, including providing a robust day-to-day leadership presence involving resource allocation, monitoring, and reporting.
TPA & Claims Management - Act as Key point technical controller on the TPA Services for the Claims Management to improve service and control in the case of claims leakages.
Conduct periodical technical audit with TPA, review performance, and represent to the HOD and CEO. Ensure that the company meets its legal and regulatory responsibilities in the underwriting, claims handling, and reinsurance activities.
Claims Quality Control - Ensure about claims philosophy along with standards of services and effective implement of company business plan with claims strategy with in budgets. Develop FWA practices with TPA and internal Risk team to monitor claims leakages.
Actuarial Pricing and Reserve Practices - Conducting medical exposure analysis to describe medical pricing report for Actuary. Convey medical business strategy to Actuary for risk valuation and risk adoption. Maintain and ensure in adequate / appropriate reserve practices has been conducting Qtr. level to enhance company financial strategy.
Reinsurance - Monitor and evaluate Reinsurance portfolio reporting for Quota and XOL plans. Review periodical contribution factors on risk retention and exposures on the medical portfolio.
Business Management - Responsible for result-oriented management and development of people and resources, including providing a robust day-to-day leadership presence involving resource allocation, monitoring, and reporting.
KPI & KRI - Perform periodic operation analysis by KPI & KRI and efficiency evaluation measures to be reported to HOD and CEO for the action plan.
Strategy - Develop implements, Re-process business, and ensure medical department all measures contribute in quality of service to the client and adequate grievance.
Conduct market research to maintain sales goals of the company for SME medical portfolio. Valuate existing SME’s product plans to enhance business-oriented plans upon market requirement.
Establishes and maintains strong, collaborative relationships with other functional managers and areas.
Represent the company in all meetings with insurers, reinsurers, External auditors, Appointed Actuary, Consultants, and other stakeholders. - Guide and educate the broader leadership community to the insurance market.
Successfully inspire, mentor, and develop teams to deliver on objectives.
As directed by the company Senior Management, any Additional technical support or responsibility.
Operations Consultant in command to Overseeing and ensuring seamless operations around all Medical products and services of the company, technical management and Ensuring the interoperability of all operational systems for the Gulf Union medical department. Responsible for the strategic and operational delivery of all Gulf Union services across the Medical Insurance portfolio.
Duties:
• Operations - Support in development and implementation of department strategy according to the company vision, responsible in setting the section’s operational goals, initiate measures and has accountability in reaching these goals to improve the overall operations performance.
• Operations - Responsible for a result-oriented management and development of people and resources, including provision of a strong day-to-day leadership presence involving resource allocation, monitoring, reporting, and conducting regular staff meetings.
• Underwriting - Develop, implement and ensure adherence of medical underwriting strategy. Exercise independent judgment & contribute analysis of date to valuate underwriting risk for medical portfolio. Conducting medical exposure analysis to describe medical pricing report for Actuary. Convey medical business strategy to Actuary for risk valuation and risk adoption.
• Re-Insurance - Monitor and valuate monthly & quarterly portfolio report for Quota and XOL plans. Review periodical contribution factors on risk retention and exposures on medical portfolio.
• System Development - Design application innovative and enhancement blue print for Medical Portfolio.
Improvement in technical system reports, Process flow, Digitalization, Business Intelligence and other system Supports.
• Quality & Controls - Develop, implements and ensure medical department all measure contribute in quality of service to client and adequate grievance. Performing periodic operation analysis and efficiency evaluation measures to be reported to Head of Portfolio for action plan.
• Business Strategies and plans - Conducting market research to maintain sales goals of company for medical portfolio. Valuate existing product plans to enhance business oriented plan upon market requirement. Executes strategic and operational plan in support of technical management objectives and initiatives.
• Establishes and maintains strong, collaborative relationships with other functional managers and areas
Operations Manager in command to Overseeing and ensuring seamless operations around all Medical products and services of the company, technical management and Ensuring the interoperability of all operational systems for the Gulf Union medical department. Responsible for the strategic and operational delivery of all Gulf Union services across the Medical Insurance portfolio.
Duties:
• Operations - Support in development and implementation of department strategy according to the company vision, responsible in setting the section’s operational goals, initiate measures and has accountability in reaching these goals to improve the overall operations performance.
• Claims - Responsible for a result-oriented Claims management, and development of people and resources, including provision of a strong day-to-day leadership presence involving resource allocation, monitoring, reporting, and conducting regular staff meetings.
• Underwriting - Develop, implement and ensure adherence of medical underwriting strategy. Exercise independent judgment & contribute analysis of date to valuate underwriting risk for medical portfolio. Conducting medical exposure analysis to describe medical pricing report for Actuary. Convey medical business strategy to Actuary for risk valuation and risk adoption.
• Re-Insurance - Monitor and valuate monthly & quarterly portfolio report for Quota and XOL plans. Review periodical contribution factors on risk retention and exposures on medical portfolio.
• Provider Network - In-charge of KSA & International Provider Network & Relation Management to review and negotiate all new or amendment of agreement, medical services prices and discounts. Monitor 750+ providers and expanding the network of service providers inside KSA and International.
• Quality & Controls - Develop, implements and ensure medical department all measure contribute in quality of service to client and adequate grievance. Performing periodic operation analysis and efficiency evaluation measures to be reported to Head of Portfolio for action plan.
• Business Strategies and plans - Conducting market research to maintain sales goals of company for medical portfolio. Valuate existing product plans to enhance business oriented plan upon market requirement. Executes strategic and operational plan in support of technical management objectives and initiatives.
• Establishes and maintains strong, collaborative relationships with other functional managers and areas.
Central Area Team Leader (Operations Claims ) at Gulf Electronic Management System Co. W.L.L. (GEMS) Riyadh - Saudi Arabia ( From June 2007 to November 2011 )
GEMS is a Third Party Administration Company for Gulf Union Cooperative Insurance Company in Saudi Arabia. Performing and service to GUCIC by GEMS three (3) Branch offices mainly located in Dammam, Riyadh & Jeddah.
Job Performance & Key Responsibility at GEMS:
• Monitor the performance of the executives for Operational Activity on a daily basis for central area . Prepare work diagram for Claim processing, Policy Claims Auditing Team.
• Process day to day transactions within set standards. Ensure the timely resolution of client queries and complaints.
• Review all claims to ensure compliance with Insurance laws / Policy terms and to ensure budgets are met. Safeguard the Company from potential losses by minimizing risk of fraud associated with Operations.
• Assist in developing to IT Management Team an integrated Claims system in Ingenious to handle claims processing, proceeds computation, requirements administration and monitoring.
• Ensure that all MIS and budgets related to Claims operations are met in a timely manner to facilitate decision making by the Health Insurance Claims Committee/ Senior Management. Ensure image of GUCIC strengthened in market place to aid business development and policy holder satisfaction.
• Key performance role playing in cost control & fraudulent claims management. Maintain claim loss ratio with fraudulent provider & monitor daily, weekly & monthly performance. Maintain action draft to present Board committee about loss, fraud & Insured utilization ratio for plan.
• Provider Network Development & agreements. Review Price list and comparisons with market rates along with GUCIC product rage levels to assignee Network class. Monthly meeting with care provider & Groups for operational services & Payable Issues.
• Maintain Operational Reports for work consistently and punctually on weekly, Quarterly & Monthly, Uses company time conscientiously. Prepare TAT planning for smooth operation works. Weekly & Monthly OPS activity reporting to Management with day to day’s observation & action with solution.
• Quality & Quantity of work with Completes assignments with thoroughness and accuracy & Demonstrates ability to manage several responsibilities simultaneously; demonstrates willingness and ability to carry a fair share of the workload with all team member.
Manager (Operations Claims ) at Paramount Health Services Pvt. Ltd. ( PHS ) Mumbai - India ( From 2002 to May 2007 )
A Paramount Health service (PHS ) is leading Third Party Administration Company in India for Health Insurance Sector. Performing & service more than 12 Health Insurance companies Private / Non Private sector.
Job Performance & Key Responsibility at PHS:
• Set Up & stagey planning for Claims Management to achieve targets for all team leaders and executives. Manage activities of department & ensures that priorities / task are completed within time frame. ( No of 35+ Claims executive / Adjustor, Team Leader and Auditor direct Reporting )
• Motivate executives to perform the best contribute to improvement in constantly work towards documentation, improvement and implementation of processing claims. Training of team members for operations activity & smooth work. ( Centerline Claims processing 24 X 7, 365 days )
• In achievement of targets concentration & assurance to complete Quality & Quantity of jobs.
• Develop good inter personal skills and encourage the team members to also have good inter personal relationship with all. Ensure the company values, vision and the norms are followed by self and team. Resolve team queries, co-ordinate with among team with final solutions.
• Prepare roadmap for team with new ideas for good team performs Maintain MIS report about team work monthly volume & work quality.
• Monitor and Coordination with all PHS Outstation Branches on Claims Operations. Planning & strategy convey to all branches follow company visions and polices for Claims Management. Productivity & Quality control of branch offices claims settlement performance. ( 15 + PHS branch offices in all over India )
• Prepare SOP (Standard Operating Procedure) for Operational Activity with Insurance company’s guidelines.
• Supervision on Technical Claims Auditors performance. Reviewing all claims are followed under proper audit level criteria or not. Policy Coverage and guideline promptly followed by claims adjuster / processer & appropriately control by Auditors. New methods and plans design to grab Fraud Claims Management.
• Coordination with IT Management for several solutions and improvement of claims settlement new methods.
Associate, Life Office Management Association, USA.
Diploma in Insurance, from the Chartered Institute Of Insurance, London, United Kingdom. LEVEL 6
Specialization in Insurance & Banking
Certificate in Insurance Level 3
Graduate in Commerece
IFCE Certifiacation