Ahmed Donia
Riyadh
Summary
Passionate health insurance expert and self-motivated. a diligent worker and astute problem-solver with strong communication skills, leadership skills, and a reliable work ethic. with a demonstrated medical background and history of working for one of the biggest insurance companies in the Egyptian and TPA Saudi markets with multiple success stories
Overview
10
10
years of professional experience
1
1
Certification
Work History
Approval Manager
Anova Health care and Applications
04.2024 - Current
- Managing team of 10 onsite and 21 offshore doctors.
- Enhanced internal controls through consistent review and update of approval-related policies and procedures.
- Increased efficiency in the review process by maintaining organized records of all submitted Approvals .
- Attending strategic meetings with stakeholders and hospital administrative team to create, enhance and maintain hospital policies.
- Communicate effectively with different insurance companies to resolve complex cases .
- Maximize patient satisfaction and improve patient’s overall journey.
- Enhanced approval processes by streamlining workflows and implementing standardized procedures.
Pre-authorization & Case Management
Total Care Saudi
Khobar, Eastern Province
07.2022 - 01.2024
- Company Overview: Khobar, Eastern Province
- As skilled professional, expertly manage and coordinate high volume of cases by providing exceptional clinical support, valuable information, efficient navigation, and seamless coordination to esteemed customers in KSA
- Unwavering commitment to excellence ensures that clients receive best possible care and support throughout their journey
- Present significant discoveries concerning identification of fraudulent activities and abuse in inpatient cases, and provide recommendations for corrective measures to be taken by management
- Increase efficiency, minimize errors, and reduce administration time
- Ability to communicate sensitively and effectively with pre-authorization and roving departments and other departments, having regard for strict need for confidentiality
- Balancing needs of business with advocacy for patients rights
- Khobar, Eastern Province
Health claims Assistant Manager
AXA Egypt
Cairo, Egypt
01.2022 - 06.2022
- Company Overview: Cairo, Egypt
- Manage a team of employees who are responsible for the assessment of the health claims
- Customers, whether local or global, manage employees, including training, guiding, auditing, quality checking, and performing monthly team meetings besides one-to-one meetings
- Calculate the monthly capacity plan and monitor the team productivity in terms of quantity and quality to maintain the claims backlog as per the set department KPIs and KSIs
- In addition to deciding rewards and promotions for team members based on performance
- Handling complaints and resolving work-related issues
- Coordinated on-site visits to maintain rapport with key accounts
- Analyzed customer feedback and developed new techniques to support retention
- Performed full account management for the assigned client portfolio with consistently positive results
- Conducted training classes, held personal meetings, and led special workshops to improve employee performance
- Creating and documenting process flows and implementing requirements for functional improvements
- Managed a large client portfolio, prioritizing claims in line with complexity and demand
- Detect and report any suspected abuse or fraud cases to the quality team for investigation
- Handle clients' and healthcare providers' objections related to rejected claims
- Resolve any conflicts that could arise within the team or between the team and the other departments
- Attend external meetings with clients or brokers
- Participate in selecting and interviewing new candidates when needed
- Perform the team members' end year review
- Update the yearly unit SOP
- Support when needed in any projects related to the health LOBs
- Hiring and training new team members
- Cairo, Egypt
Medical Claims Supervisor
AXA
Cairo, Egypt
01.2018 - 12.2021
- Company Overview: Cairo, Egypt
- Supervising reimbursement local and international reimbursement claims team to ensure maximum quality and adherence to AXA reimbursement guidelines
- Regular auditing of team members' medical and financial claim processing against AXA guidelines and policies
- Organizing workflow and ensuring that each member of team understands duties or delegated tasks
- Monitoring team members' productivity, providing constructive feedback, and coaching
- Handled all claims and communications within established service level agreements
- Managed allocated caseload of complex and high-value claims
- Handled initial claim inquiries with attention to first-class, personal service
- Cairo, Egypt
Medical Claims Officer
AXA
05.2016 - 01.2018
- Collaboration with medical claims and other departments to reach maximum customer satisfaction
- Dealing with different claims at different levels, directly with medical providers and insured with high accuracy within policy terms and conditions
- Processing appeals and corrected claims, researchers, and reconciling credit balance accounts
- Participating in quality assurance plans
- Followed up on all client requests and verified resolution
- Evaluated claims data and market trends for improved customer understanding
- Handled all claims and communications within established service level agreements
Medical Claims Officer /Senior DOS
Allianz worldwide partners
Cairo, Egypt
05.2015 - 05.2016
- Company Overview: Cairo, Egypt
- Collecting all outstanding balances for specific group of payers to assure maximum reimbursement
- High cost claims handling and problem solving with Negotiation with both medical providers and payers Managing More than 40 primary care physicians with strong collaboration with each team member
- Monitored and recorded patient conditions, carrying out and reporting regular observations
- Cairo, Egypt
Primary Care Physician
Allianz worldwide partners
Cairo, Egypt
11.2014 - 05.2015
- Company Overview: Cairo, Egypt
- Allianz Worldwide Partners: Doctor on site at NTRA, Egyptian Competition Authority, Carrefour, Golden State Food, and Dar El Handasa
- Egypt branch responds to medical/health problems presented by patients, including history taking, diagnosis, investigation, treatment, and referral as appropriate
- Maintaining confidentiality and impartiality
- Commissioning healthcare by liaising with medical professionals in community and hospitals
- Promoting health education in conjunction with other health professionals
- Organizing preventative medical programs for individual patients
- Providing specialist clinics for specific conditions or for certain groups, e.g., diabetes, smoking cessation, and new babies
- Upholding patient trust and confidentiality by managing information with discretion
- Quickly responded to medical emergencies, working calmly and professionally under pressure
- Cairo, Egypt
Education
Continuing education courses in LOMA -
Life Office Management Association
Insurance Foundation Certificate Examination (IFCE) -
SAMA
01.2023
Bachelor of Medicine, MBBCh -
Ain Shams University
Egypt02.2014
Secondary Education -
Shakhbout Ben Sultan Al-Nahyan School
UAE05.2004
Skills
- Leadership
- Time management
- Problem-solving
- Strong negotiation skills
- Customer-centricity
- Strong communication skills
- Business etiquette
- Handling multiple tasks
- Adapting to stressful situations
- Computer skills
- MS Office
- Crisis Management
- Case management skills
Certification
- Leadership Skills
- Communication Skills
- Emotional Skills
Accomplishments
- Supervised a team of 15 employees, emphasizing business control and customer satisfaction.
- Developed documented Standard Operating Procedure (SOP) variances.
- Implemented new processes that increased team productivity.
Languages
Arabic
English
Hobbies and Interests
- Reading
- Traveling
Personal Information
Nationality: Egyptian
Timeline
Approval Manager
Anova Health care and Applications
04.2024 - Current
Pre-authorization & Case Management
Total Care Saudi
07.2022 - 01.2024
Health claims Assistant Manager
AXA Egypt
01.2022 - 06.2022
Medical Claims Supervisor
AXA
01.2018 - 12.2021
Medical Claims Officer
AXA
05.2016 - 01.2018
Medical Claims Officer /Senior DOS
Allianz worldwide partners
05.2015 - 05.2016
Primary Care Physician
Allianz worldwide partners
11.2014 - 05.2015
Continuing education courses in LOMA -
Life Office Management Association
Insurance Foundation Certificate Examination (IFCE) -
SAMA
Bachelor of Medicine, MBBCh -
Ain Shams University
Secondary Education -
Shakhbout Ben Sultan Al-Nahyan School