Expert in Medical Excellence- Management (Preauthorization/ Reimbursement)
Expert 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.
|Year: 2018||Degree: MSc||Subject: Healthcare Management||Institution: Anglia Ruskin University - Cambridge/Chelmsford|
|Year: 2007||Degree: MBBS||Subject: Medicine & Surgery||Institution: Baqai Medical University|
|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.
|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.
|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.
|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.
|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