Profile
• A dynamic professional possessing nearly 12 years of experience in:
~Insurance Coordinator & Claims Processor ~Liaison&Coordination ~Customer Service ~Auditing ~Team Management
• Possesses a clear understanding of the Insurance industry with the distinction of instituting new practices to achieve business excellence at the lowest overall cost.
• Expertise in analyzing various systems & procedures and implementing risk assessment tools for facilitating effective decision making by the management; knowledge of medical codes such as (ICD 9CM,ICD10CM,CPT, HCPCS and drug code)
• Extensive experience in Insurance: Approval criteria, Policy servicing and Claims processing (including claims evaluation, processing, auditing and reporting)
• An effective communicator with distinguished abilities in motivating, training and retaining team members for successful process operations.
Core Competencies
• Formulating & implementing Insurance guidelines, processes, workflow, application forms, etc.
• Overseeing claim procedures involving validity assessment and approvals of high value claims in compliance with regulatory requirements
• Setting out quality standards for various operational areas and ensuring a high-quality customer experience, while adhering to the SLAs and work processes
• Administering customer centric operations, forwarding customer instructions to the concerned department and ensuring customer satisfaction by achieving delivery & service quality norms
• Managing long-term insurance claims, reassessing them regularly & making recommendations for the settlement of claims
• Creating and sustaining a dynamic environment that fosters development opportunities and motivates high performance amongst team members
Career Summary
Oct’09 – Aug’14:
Al Madallah Healthcare Management Services, Dubai
As a Medical Claims Processing Supervisor
Key Result Areas:
• Handled calls related to various queries &qualifying information from clients, members &providers
• Accounted for logging all telephone enquiries, updating member’s medical file, medicine lists as per policy, medical coding guidelines &coding (ICD 9CM,ICD10 CM CPT, HCPCS and drug code)
• Expedited& completed the administrative and demographic portion of the pre-authorization screen module for each request received from the provider/ clients / members
• Served as a SPOC for activities related to claims including claims evaluation, processing, auditing and reporting; handled outpatient claims such as UAE network submission claims, resubmission claims, reconciliation, international claims, and reimbursement claims
• Managed all international cases & established an international client network (Member claims from international network hospital ,clinic , pharmacies)
• Liaised with some major local & international insurance companies, TPA’s & insurance brokers
• Contributed in developing, updating &implementing the guidelines for evaluation &processing of medical claims as well as policies procedures related to medical claim review process
• Assisted in all Pre-authorization requirements for inpatient admission
• Visited providers for follow up on clients & gathered feedback on their health status
• Confirmed accurate application of contractual prices & discounts, schedule of benefits, correct allocation of benefits, collection of deductibles, co-payments, observance of policy limits and adherence to claims submission protocols
• Audited claims to ensure completeness & correctness of batches as per certain auditing criteria, guidelines and applied the high cost authority matrix when needed
• Examined medical necessity& consistency in diagnosis procedure &drug codes &descriptions stated on the claims according to accepted medical coding rules and guidelines
• Imparted training to members on processors & about insurance protocols, processing claims and answering common processing queries W.R.T. policy, terms and conditions
Highlights:
• Holds the merit of implementing E- prescriptions , e-claim processing –with drug codes in web based software systems in the organisation to ensure proper documentation of claims forms
• Received Best Employee of the Year from the employers for MOH drug list classified according to policies , and implemented in software
• Efficiently handled problems like High cost claims in all pharmacy and medical related issues as opportunities and dealt with difficult challenges by implementing e-claims system updates and Verbal approvals by call centre
• Tactfully dealt with clients like Non coverable members , Doctors ,pharmacist and demonstrated excellent leadership skills that helped in solving major issue – Exclusions , other policy related issues
• Competently built long-term and profitable relationships with clients by offering them best policy coverage , good network providers, best call centre support solution for various complaints
Feb’07 – Aug’09:
Fathima Healthcare Management Services, Dubai
As Insurance Officer
Key Result Areas:
• Handled both Outpatient & Inpatient approval requests from providers & clients.
• Coordinating with providers and qualifying information needed to access cases.
• Evaluating Approval requests both medically & policy wise to grant approval/rejection.
• Accounted for claims evaluation/ processing/ re-conciliation of claims verifying all evaluated claims before sending to the provider.
• Evaluated re-imbursement claims such as international claims and non-network claims
Previous Experience:
Nov’04 – Nov’06:
PWC Logistics, Kuwait (Ministry of Health Project – Central Medical Store Administration)
As a Stock controller
Oct’02 – Nov’04:
Sriram Medicals, Ayyampet ,Thanjavur
As a Pharmacist
IT Skills
• MS Office Suite, Photoshop Literate, Windows & Internet Applications
• Typing Speed – 50wpm
Qualifications
• Bachelor of Pharmacy from Thanthai Roever College of Pharmacy, Perambular, Dr. MGR Medical University, Chennai
In 2002
Courses
• Industry program in Clinical Trials, Research &Administration from Bioinformatics Institute of India, Noida, in 2013
• Advanced Medical coding and Billing (AMCB)from ALDOS MEDICAL SERVICES PVT LTD
• Information Technology Professional (ITP) includes [ICD-10 and 5010 Mandate – A Technology View, Health Insurance an Orientation, Overview of Payer IT ]from American Health insurance Plan (AHIP)
• Basics of Health Insurance from UDEMY
• Understanding HIPAA for the Medical Office from UDEMY
• Business of Medicine from UDEMY
• Medical case studies from UDEMY
• Forum Professional in Supply Chain Management from Sify in2006
