Senior Manager-Consumer Lines Claims\Medical
ADNIC - Abu Dhabi National Insurance Company
Total years of experience :21 years, 2 Months
Head of Medical Rule engine - Automation of medical claims:
Privileged with a full oversight to the medical claims management and operations. Responsible for the Medical Claims Enhancement with an objective to streamline and improve the processes of the Managed Care Operations while reflected my medical background and insurance business knowledge by designing efficient and cost effective solutions that have empowered the different workflows i.e.: E-Claims, Reimbursement Claims, Prior Authorization and the Direct Billing for overseas treatment.
Leading a team of Licensed Physicinas, Medical Coders and Claims Analysts. Personally chairing ADNIC’s Clinical Committee and ADNIC’s Authorization and Exclusion Committee
Achievements:
Process Improvement and Efficiency:
o Created a paperless work flow in Direct Claims and Prior Authorized Claims with efficient and timely TATs.
o Claims Adjudication: Designed an “Edits Rule Engine” work flow integrated with web based internationally accredited software cross matching the diagnosis with the requested services. This has supported the claims management and assured consistent decision making and guaranteed instant billing system availability and appropriate claims settlement to healthcare providers
o Auto Adjudication: utilizing the Rules Engine intelligence to auto process 80% of claims.
Financial Governance and Cost Containment:
o Applied claims processing controls, billing methodologies, clinical pathways and initiated audit procedures resulted in aggressive savings and financial recoveries against earned premiums.
Strategic Design Support:
o Member in the Risk Management Committee and the Medical Product Initiative.
o Contributed to medical insurance products design.
Head of Pharmacy Rule engine - Pharmacy Benefits Management:
Honnored with the first medical insurance company to implement the PBM (Pharmacy Benefit Management) within GCC. Implemented strategies affecting Pharmacy claims and prescriptions, developing drug utilization review and evaluation, troubleshooting claims processing issues, evaluating services and products, participating on therapeutic committees.
I lead a team of Licensed Pharmacists, Medical Coders and Claims Analysts.
Achievements:
Process Improvement and Efficiency:
o Maintain ADNIC pharmacy network for the purpose of ensuring effective and efficient networking systems.
o Perform quality review on all orders set to quality assurance, complete knowledge of pharmacy order process flow, maintain working knowledge of changes in pharmacy practice, including pharmacy laws and drugs, and apply this knowledge in the performance of daily activities.
o Supporting different functions of various volume pharmacies, including quality control, and customer consultation.
o Auto Adjudication: utilizing the Pharmacy Rules Engine intelligence to auto process 95% of claims.
Pharmacoeconomic and Health risk Governance:
Clinical Design Support:
Pharmacy Provider relations:
Head of Health Support System:
Personally represented all the private health insurers for the Emirate of Abu Dhabi in the Disease Management Program - Department of Health Abu Dhabi (DOH) and was a motivated and proactive member of the ADNICity Life Committee member.
Achievements:
Disease Management and Patient Support Program:
Health Education and Awareness Campaign :
Health Management Alerts
Cardiovascular Specialty Pharmacist
- Review all physician medication orders and administer appropriate dosage and recommend all therapy changes to patients if required.
- Counseled patients on compliance techniques, the benefits of continuing to take hypertension or cholesterol medications, updated profiles when necessary, or assisted with any questions or concerns of the patient. Also managed the drug utilization reviews for patients with cardiovascular drug interactions.
- Contacted patients with cardiovascular medications that had not been refilled when expected.
Key Accomplishment :
University of Florida, College of Pharmacy Cardiovascular Certificate Program
Medco Gatekeeper Recognition Program Award for senior Citizens referral .
Medco WOW Award for outstanding customer service experience
In charge for filling prescriptions, counseling patients, maintaining proper paperwork, customer satisfaction, floating to other pharmacies, proper pharmacy workflow, and error prevention.
Perform all necessary functions, including providing information on all prescription and non-prescription medications and products.
Manage and schedule pharmacists into stores to make sure adequate coverage is maintained.
Implement an outreach program and planned pharmacists for community service presentations.
Train pharmacy technicians to become proficient with the Rx computer systems and learn the company paperwork and objectives.
Purchase pharmaceuticals and arrange for return of outdated or recalled medications, monitored and maintained inventory.
Maintain highest levels of customer satisfaction at all times, and resolve any customer service issues.
Supervise and train personnel and new pharmacists, and prepare shift schedules as necessary.
Participate in pharmacy acquisitions and pharmacy relocations and execute ¡§special projects¡¨ to increase prescription volume in problem stores.
Key Accomplishment:
Award for the most vaccinating pharmacy in the whole district.
Review all medical claims on all risk contracts for payment accuracy and recovery.
Obtain and review all necessary medical records and billing information data from centers, hospitals, nursing homes, etc. in line with HIPAA requirements.
Evaluate each claim submission for appropriate eligibility coverage of specific services application of plan benefits and application of state and federal legislation application of proper compensation rules and laws.
Provides support to customer service by answering complex claim questions and handling in and outbound customer service calls when necessary.
