أحمد ابو عمره

• إدارة عمليات التأمين والموافقات الطبية بكفاءة عالية لضمان تقديم الخدمات الصحية بشكل سلس.

• تقييم الطلبات الطبية بدقة لضمان توافقها مع السياسات التأمينية المعمول بها.

• التنسيق مع مقدمي الخدمات الصحية لتسهيل الحصول على الموافقات اللازمة.

• تحسين إجراءات العمل من خلال تطوير استراتيجيات فعالة لزيادة سرعة معالجة الطلبات.

• تقديم دعم فني للأفراد في قضايا التأمين والموافقات الطبية، مما ساهم في رفع مستوى رضا العملاء.

• تحليل البيانات المتعلقة بالموافقات لضمان تحقيق الأهداف المحددة وتحسين الأداء العام للقسم.

• بناء علاقات قوية مع شركات التأمين لتعزيز التعاون وتحسين الخدمات المقدمة.

Led the end-to-end NPHIES implementation and mapping project, transitioning from initial stages to
SBS V3 for the entire group, managing over 34 complex pricelists.
Executed monthly SFDA code updates, ensuring 100% compliance with GTIN and generic code
standards to prevent billing discrepancies.
Mastered the mapping and implementation of MOH (Ministry of Health) pricelists, ensuring seamless
integration with group-wide systems.
Headed the Medical Approval and Medical Auditteams, establishing a high-performance culture
that reduced initial claim rejections by 90%.
Supervised and mentored a large team of medical coders, ensuring coding accuracy across all
group facilities using ICD-10-AM and CPT standards.
Conducted high-level negotiations with insurance companies to resolve complex claim disputes and
maximize reimbursement.
Utilized advanced data analysis to identify root causes of rejections, resulting in a sustainable
increase in the groups net income.

Performed comprehensive medical audits for 3 hospital branches to guarantee error-free insurance
claims.
Conducted Pre-submission reviews to proactively identify and resolve potential rejection causes.
Ensured full compliance with insurance provider protocols and medical necessity guidelines.

• Conducted thorough medical revisions to ensure compliance with insurance policies and regulations.

• Analyzed and audited insurance claims for accuracy, identifying discrepancies and ensuring proper documentation.

• Collaborated with healthcare providers to clarify medical information and support claim validation.

• Utilized analytical skills to streamline processes, reducing claim processing time by implementing efficient auditing techniques.

• Developed detailed reports on audit findings, contributing to improved claim management and risk assessment.

• Enhanced understanding of insurance regulations and healthcare practices, preparing for a role as a مراجع تأمين أو ما يقاربه.

• Conducted thorough audits of medical records to ensure compliance with health regulations and insurance policies.
• Collaborated with healthcare professionals to identify discrepancies and improve billing accuracy.
• Analyzed patient treatment plans to verify the necessity and appropriateness of services rendered.
• Developed and implemented auditing procedures that enhanced operational efficiency and reduced errors.
• Provided training and support to staff on best practices in documentation and coding for insurance claims.
• Contributed to a significant reduction in claim denials through meticulous review and proactive communication with insurers.
• Maintained up-to-date knowledge of healthcare regulations and insurance guidelines to ensure adherence.

• Developed strong relationships with healthcare professionals, enhancing trust and collaboration in the pharmaceutical sector.

• Conducted detailed product presentations and educational sessions, improving product knowledge among medical staff.

• Analyzed market trends and competitor activities, providing valuable insights to optimize sales strategies.

• Achieved and exceeded sales targets consistently, demonstrating a strong ability to drive revenue growth.

• Collaborated with cross-functional teams to ensure seamless communication and alignment on product launches.

• Gained extensive experience in navigating regulatory environments, which is crucial for a role in insurance review.

• Leveraged strong negotiation skills to secure favorable terms and conditions, benefiting both clients and the company.

Executed technical and medical revisions for diverse claim types, including Inpatient (Hospitals)
and Outpatient services (Labs, Radiology, Polyclinics, and Pharmacies
Verified Medical Necessity and technical documentation for multi-disciplinary claims to ensure
accurate reimbursement.
Analyzed clinical data to resolve billing disputes and ensure Claim Integrity.

• Assisted in the evaluation and processing of insurance pre-approval requests, ensuring compliance with company policies and regulations.

• Collaborated with healthcare providers to gather necessary documentation, enhancing the efficiency of the approval process.

• Analyzed patient information and insurance coverage to determine eligibility, resulting in a 20% reduction in processing time.

• Maintained accurate records of pre-approval requests and outcomes, contributing to improved data management and reporting.

• Provided exceptional customer service by addressing inquiries and resolving issues related to pre-approval, fostering positive relationships with clients.

• Developed a keen understanding of insurance policies and procedures, positioning myself as a knowledgeable resource for team members.

Managed the end-to-end Pre-Approval process for various medical services, ensuring
treatments aligned with medical necessity and insurance policy coverage.
Acted as a primary point of contact between healthcare providers and the insurance company
to expedite urgent approvals and resolve authorization discrepancies.