Insurance & Medical Director
Zahrat Al-Amal Medical Polyclinic
مجموع سنوات الخبرة :13 years, 5 أشهر
• Overseeing the day-to-day clinical operations of the polyclinic, including patient care and clinical programs.
• Creating and implementing clinical policies and procedures
• Leading the quality team to get CBAHI accreditation through implementing and managing quality improvement initiatives
• Hiring, training, and supervising medical staff
• Overseeing the polyclinics electronic medical records and insurance claims.
• Following up with insurance companies about the rejected claims for medical reasons
• Managing the polyclinics budget and resources in cooperation with the financial department
• Ensuring compliance with all applicable laws and regulations of the Ministry of Health
• Representing the polyclinic to the public and to other healthcare organizations
MEAHCO Offshore Office Medical Claims Supervisor - promoted toClaims Section Head
• Managed a team of 12 employees (3 Supervisors, 3 Seniors, and 6 Specialists).
• Managed a large volume of medical claims daily.
• Maintained knowledge of claims benefits, claim processing, claims principles, medical terminology and procedures, and insurance regulations.
• Evaluated accuracy and quality of data entered into the hospital information management system.
• Reviewed and verified medical coding information to report services using ICD10 and HCPCS.
• Followed up on potentially fraudulent claims initiated by the hospital billing team.
• Trained the team how to use NPHIES portal for approvals, claims submission and resubmission.
• Followed up on paid or denied medical claims by contacting all insurance companies in KSA
• Resubmitted rejected or pended claims after editing to achieve financial targets and reduce outstanding rejections.
• Modified and updated the existing revenue cycle process to meet the desired goals and exceed them.
• Leading a group of doctors, nurses, and admins delegated to the main key accounts to offer high-quality medical service reducing the monthly cost.
• Offered friendly and efficient service to key customers, handled challenging situations with ease. Actively listened to customers requests, confirming full understanding before addressing concerns.
• Participated in continuous improvement by generating suggestions and engaging in problem-solving activities to support teamwork.
• Created multiple spreadsheets using Microsoft Excel and trained the team on data entry. Finally, got a useful analysis out of it.
• Detected some fraudulent behaviors from the customers.
• Head of the Insurance Department: supervision of all daily operations such as confirmation of coverage, a guarantee of payment, medical reports, final invoices, and claims submission.
• Responsible for the rejections and reconciliation discussions.
• Head of the International Network Department, expanding the network of insurance companies contracted or other healthcare service providers partnered with.
• Managing all the training provided to the medical staff working for 247 Clinic facilities in touristic places by regular visits.
• Building productive working relationships internally & externally
• Process development to improve the revenue cycle.
• Awareness of work required at the next level & working at that standard.
MedicalClaims Auditorpromoted toMedical AuditManager
• Supervised the approvals team responsible for the daily customer handling and submitting approvals to the insurance and contracted companies.
• Trained the claims team to perform comprehensive audits of claims invoices, medical reports, and attached documents to ensure the accuracy of the data and compliance with contract terms.
• Performed deep analysis of the monthly claims to determine the root cause of the error and fix it.
• Reviewed inpatient long stay and asked the medical department for justification.
• Investigated and analyzed complicated medical claims to prevent fraud.
• Worked closely with various departments such as patient accounts & medical records to ensure internal lines of communication are kept open and to develop the process between us.
• Followed up on deductions and rejected claims by making regular visits to insurance companies and contracting parties to discuss deductions and make the final reconciliation.
- Issued approvals for medical procedures if medically justified.
- Issued approvals for prescriptions and monthly medications.
- Made regular visits to the top hospitals to review the inpatient stay and medical records, also to check the medical justification and appropriateness of care.
- Resolving patient complaints and handling them with patience and professionalism.
- Cultivating a climate of trust and compassion for patients.
- Referring high cost and specific cases to head office to take decisions.
• Audited large volume of medical claims daily.
• Evaluated appropriateness and quality of data entered into the health information management system.
• Checked the medical reports, invoices, and other attached documents.
• Followed up on potentially fraudulent claims submitted by service providers.
First Lieutenant Doctor in the Military Medical Council
General Practitioner in the Ministry of Health - Alexandria Health Directorate
1 Year Training Program for House Officer Doctors
Contemporary Management Managerial Economics Accounting & Financial Reporting Applied Statistics Marketing Management Human Resources Management Managerial Finance Operations Management Hospital Financing & Insurance Schemes Hospital Information Systems Hospital Quality Management Physical Facility Management Monitoring & Evaluation of Hospital Services Research & Business Reporting Costing & Pricing of Hospital Services Strategic Management
Associate Degree - affiliated by AAST
MBBS