وائل والي

• Improved medical approval processes to minimize Approvals rejections and ensure optimal patient care.
• Maintained accurate and up-to-date information regarding insurance contracts with the hospital system.
• Provided expert advice to hospital administration on insurance matters.
• Conducted insurance awareness sessions for new medical staff to educate them on relevant regulations.
• Reported on the performance of the pre-authorization team.
• Managed complaints received from (IA or CCHI) and implemented corrective actions.
• Followed up with the medical team, to ensure services are ordered correctly in the system.

- Improved medical Approval processes to minimize Approvals rejections and ensure optimal patient care.
- Maintained accurate and up-to-date information regarding insurance contracts with the hospital system.
- Provided expert advice to hospital administration on insurance matters.
- Conducted insurance awareness sessions for new medical staff to educate them on relevant regulations.
- Reported on the performance of the pre-authorization team.
- Managed complaints received from (IA or CCHI) and implemented corrective actions.
- Followed up with the medical team, to ensure services are ordered correctly in the system.

- Conducted on-site investigations at healthcare providers to identify potential fraudulent medical practices.
- Analyzed data to recognize trends and detect fraudulent activity in medical claims.
- Generated reports to monitor client medical insurance utilization and detect potential misuse.
- Led a team of investigators in identifying and preventing medical fraud.
- Developed and implemented protocols to detect fraudulent activity.
- Investigated inquiries from regulatory bodies and policyholders regarding potential fraud.
- Performed audits of medical and dental claims to identify fraudulent activity.
- Communicated effectively with all stakeholders.
- Ensured adherence to quality control standards for medical claims review.
- Provided support to other departments.

- Process and assess pre-authorization requests for inpatient and outpatient medical services.
- Review patient service requests to ensure compliance with insurance guidelines and regulations.
- Expedited approvals to minimize patient wait times, achieving a target of 15 minutes or less.
- Analyze fraud data to prevent future occurrences and support informed management decisions.
- Investigate medical records to identify and address potential instances of malpractice or fraud.
- Assess medical necessity and determine insurance coverage for requested services.
- Investigate cases and collect data to monitor healthcare utilization patterns and optimize costs.