Expert Details
Medical Excellence- Management (Preauthorization/ Reimbursement)
ID: 736449
Saudi Arabia
- Currently serving as Medical Excellence Manager; qualified MBBS, Lean Six Sigma Black Belt from Michigan institute and Gold Medalist in MSc Healthcare management from Anglia Ruskin University.
- Proven track record in medical affairs management, cost effectiveness and implementation of medical process improvement projects to ensure customer satisfaction.
- Demonstrated abilities at securing the internal quality check and minimize the medical liabilities due to wrong or unjustified decisions.
- Skilled in taking active part in all activities related to smooth running of the daily work of the team including CME / system upgrade/ reporting and research.
Highlights of experience and Knowledge
- MBBS, MSC Healthcare Management
- Proficient at ensuring patient safety and better customer experience by re-adjudicating all the Medical Rejection and consistently introducing the culture of basic continuous medical education among staff
- Skilled in taking active part in all activities related Medical education and CME Presentation along with Fraud and Abuse Management.
- Medical Management along with leading Kaizen healthcare projects for process improvement
- Secure internal quality check to minimize errors.
- An effective communicator with excellent relationship management skills and strong analytical, leadership, decision-making, problem solving & organizational abilities.
Education
| Year | Degree | Subject | Institution |
|---|---|---|---|
| Year: 2018 | Degree: MSc | Subject: Healthcare Management | Institution: Anglia Ruskin University - Cambridge/Chelmsford |
| Year: 2007 | Degree: MBBS | Subject: Medicine & Surgery | Institution: Baqai Medical University |
Work History
| Years | Employer | Title | Department |
|---|---|---|---|
| Years: 2014 to Present | Employer: Undisclosed | Title: Manager- Medical Excellence | Department: Medical Operations |
Responsibilities:- Leading Healthcare operations projects for process improvement such as Kaizen and Medical Referral Project- Highlighting and reporting abusive and over utilizing trends to relvant departments; tracking and reporting groups, members and providers trends of breaching policy. - Aligning with Pharmaceutical benefits team for updated Medication coverage criteria. - Handling complaints from Social media unit ensuring image of organization is well maintained on such platforms. - Highlighting possible Medical Malpractice case to Medical care Department to ensure member’s safety. - CME/Medical case presentations, Medical Guideline Education to ensure team is adherent to it - Case discussing with treating Doctors relevant to policy or medical query whenever required; supporting customer service in managing complicated cases through AVAYA service. - Securing the internal quality check and minimize the medical liabilities due to wrong or unjustified decisions; actively contributing in improving the QDI scoring (Achieving the target of Zero A & B QDI). - Ensuring the medical decisions are consistently implemented by continuous medical education to staff in accordance with BUPA clinical guidelines. - Taking active part in all activities related to smooth running of the daily work of the team including system upgrade/ reporting and research; participating and serving on unit’s committees and task forces. |
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| Years | Employer | Title | Department |
| Years: 2012 to 2014 | Employer: Bupa Arabia | Title: Medical Specialist | Department: Medical Pre Authorization |
Responsibilities:- Achieved the response time of more than 85% set by the business as well as daily contribution target of 255 Daily.- Actively contributed in improving the QDI scoring (Achieving the target of Zero A & B QDI); secured the decision making is in line with contractual and legal terms and conditions. - Achieved the response time targeted by the business as well as contribution target set by the business. - Responsible for VIP case management and management of Avaya Call System within team to ensure customer care gets enough support - Took active part in all activities related to smooth running of the daily work of the team including system upgrade/ reporting and research. - Participated actively in the coaching and capability building programs and activities of the pre authorization department. |
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| Years | Employer | Title | Department |
| Years: 2011 to 2012 | Employer: Med Net Saudi Arabia LLC (Munich RE) | Title: Medical Claims Doctor | Department: Medical Claims Center |
Responsibilities:- Negotiated care path with treating Physician/Surgeon/ liaising as necessary adjudication of Claims received from providers; visited providers to check on patient progress.- Handled preauthorization request received from providers; involved in setting financial and length of stay limits; monitored progress of patients for international preauthorization. - Responsible for in patient/outpatient referral cases medically adjudicate the following claims for medical appropriateness over SR1000 with detailed reasons for full/part decline. - Took care of referrals from Medical Officers and audit hospital records as required; checked hospital records against claims submitted. - Adherence to ICD 9 Coding - Implemented the policies & procedures further to suit with the demand of the business; ensured that the policies and procedures have been approved updated, coordinated and integrated with the overall processes of the company. |
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| Years | Employer | Title | Department |
| Years: 2010 to 2011 | Employer: Abbasi Shaheed Hospital, Karachi | Title: House Officer/Surgeon | Department: Various |
Responsibilities:- Daily ward rounds with consultants and case discussions- Handling In Patient medication and Lab investigations - ER duties along with Emergency management of acute cases such as Appendicitis and RTAs - Assisting in various surgical procedures such as ORIF, Appendectomy, Hip Arthroplasty etc. - On Call duties to ensure 24/7 patients support. - OPD Shifts. |
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Career Accomplishments
| Licenses / Certifications |
|---|
| Six Sigma Black Belt in Healthcare from Management and strategy Institute America PAHM From American Health Insurance Plans Saudi Health Council Registration Certificate/ License Pakistan Medical And Dental Council License |
Language Skills
| Language | Proficiency |
|---|---|
| English | Fluent |
| Arabic | Fluent |
| Urdu | Native |
| Hindi | Native |