Ahammed Afzal

Health Care Billing and Insurance Claims/Specialis

Sameera Medical Center

Jeddah

10.2018 - Current

BUPA,TAWUNIYA,ALRAJHITAKAFUL,GLOBEMED,AXA,MALATH,SAICO,GULF UNION
Provide remote colleague educational sessions on issues identified during the audit process
Responsible for providing billing compliance education to all physicians and advanced practice practitioners within the division
Provide feedback of audit findings to physicians and conduct post-audit training sessions as audit results
Supervising and processing the In-Patient approvals
Medical and policy adjudication of admitted cases in the visited hospitals based on the medical data and investigations reports in the patient’s file and the medical discussion with the treating doctor if necessary (Approve/Reject)
Ensuring that the correct current procedural terminology, or CPT, and international classification of disease, or ICD-9, codes are used
Determined if reported medical claims are fraud or process error, which required looking into physical claims, batch analysis, statements review, personal visits to the provider to inspect hospital records, and placing phone calls on suspected claims Requirements As a medical claims auditor, you'll need to rely on a range of analytical, technical and interpersonal skills to successfully complete most professional tasks
Some specific skills may include:
The ability to match the information in medical records, such as diseases, with their proper codes
The ability communicate patient data with other medical personnel
The ability operate computerized coding technology
The ability to pay strict attention to details
The ability to follow instructions in precisely the manner in which they are laid out, Responsible for auditing or adjudicating the OP medical claims and play a role in maintaining the unit production Responsible for finalizing the claims payment with in define period of time Responsible for Health care providers profiling and focus billing trends of providers Work on claims rejection summery and assist in maintaining the quality of provider’s monthly statements Work on the claims data and assist in analyzing and reporting the abusive and fraudulent behaviors and billing from providers
Assist in preparing the claims quality and rejections reports and help the reconciliation unit to finalize the open account and final settlement with Providers
Support the departmental strategies & play a vital role in maintaining the Quality of Medical managements from provider’s side by giving regular feedback on claims and treatment quality
Excellent written and verbal communication skills
Fluent in English language
Knowledge of automated utilization review and data analysis systems
Knowledge of health care standards appropriate to specific claim
Knowledge of statistics and quantitative analysis methods
Knowledge of medical, pharmaceutical, and other health services, practices, and terminology
Knowledge of medical reimbursement policies, procedures and standards
Knowledge of health care billing standards and procedures.
Submitted electronic/paper claims documentation for timely filing.
Managed large volume of medical claims on daily basis.