Dr Umar Muhammad Muslim
Jeddah,Saudi Arabia
Summary
Results-driven professional with expertise in project management, AI and digital transformation, and KPI tracking. Demonstrates exceptional skills in decision-making, complex problem-solving, and time management, coupled with technical proficiency and interpersonal effectiveness. Adept at leveraging customer relationship management systems to enhance client satisfaction and streamline operations. Recognised for excellent oral and written communication abilities, quick learning aptitude, and a strong focus on achieving organisational goals through innovative solutions.
Experienced professional with focus on management and team leadership. Capable of driving projects to successful completion through strategic planning and strong interpersonal skills. Known for fostering collaborative environments and delivering consistent results.
Overview
8
8
years of professional experience
8
8
years of post-secondary education
1
1
Certification
Work history
Reimbursement manager for eastern region
TAWUNIYA INSURANCE COMPANY
Khobar, Eastern Province
2024.12 - 2026.05
- Managing the entire Reimbursement system from claims till payout.
- Coordinated cross-departmental collaboration for improved workflow.
- Network Oversight: Managing relationships with hospitals, clinics, and pharmacies across the designated region to ensure compliance with insurance contracts.
- Agreement Reviews: Identifying prospective medical providers and reviewing service agreements to ensure regional coverage and cost-effectiveness.
- Recovery Optimization: Identifying "exhausted benefits" and working with re-submission teams to maximize recovery.
- Led performance reviews, identified areas for improvement.
- Delivered high-quality to increase customer satisfaction.
- Boosted department efficiency by streamlining operational processes.
- Implemented cost reduction measures, reduced overhead expenses.
- Reserving: Monitoring outstanding claims and collaborating with the Finance Department to ensure claim reserves are adequate for the region’s volume.
- Compliance & Fraud Control
- Protocol Adherence: Ensuring all medical claims and reimbursements strictly follow SAMA, CCHI, and internal insurance protocols.
- Fraud Investigation: Overseeing investigations into unjustified cases or high-value claims to mitigate financial leakage.
- Strategic Performance & Reporting
- Data Analysis: Evaluating reasons for claim disallowances, identifying systemic improvement areas, and implementing changes.
- Target Management: Achieving monthly regional targets regarding claim processing speed (TAT) and accuracy.
- Reporting: Preparing comprehensive statistics including claim costs, average claim ratios, and regional performance metrics.
- Team Leadership
- Operational Management: Planning and facilitating team meetings to share product knowledge and resolve complex customer or provider inquiries proactively.
- Staff Development: Coaching insurance team members and managing work distribution to maintain departmental productivity.
Pre-Authorization Doctor
TOTAL CARE SAUDI
Khobar, Saudi Arabia
2022.07 - 2024.01
- Working on following Projects under TCS: Cigna worldwide- Gossi - Arabian Sheild - Cumberland - Buruj - Acig - UCA - Sagar - Hajj and Umrah by Ministry of umrah
- Verifying insurance eligibility and benefit levels to ensure adequate coverage for identified services prior to receipt
- Successfully working with payers via electronic/telephonic and/or fax communications
- Responsible for verification and investigation of authorization, and referral requirements for patients
- Coordinates and supplies information to the review organization (payer) including medical information and/or letter of medical necessity for determination of benefits
- Collaborates with designated clinical contacts regarding encounters that require escalation to peer-to-peer review
- Communicate with patients, clinical partners, financial counselors, and others as necessary to facilitate authorization process
- Facilitates submission of clean claims and reduction in payer denials by adhering to both organizational and departmental policies and procedures and maintaining departmental productivity and quality goals.
- Worked in multidisciplinary teams to provide comprehensive care.
- Utilised diagnostic tools for accurate disease identification and treatment planning.
- Ensured smooth operation of the clinic, maintaining high standards of healthcare services.
- Assisted in staff training sessions to share knowledge and experience.
- Managed emergency situations effectively, prioritising patient safety.
- Maintained continued personal development to improve [Type] professional knowledge and competence.
- Carefully managed admission and discharge of [Type] patients in line with [Type] department policies and targets.
Approval and Roving Doctor
Gulf-Union Insurance Company
Dammam, Saudi Arabia
2020.10 - 2022.07
- Verifying insurance eligibility and benefit levels to ensure adequate coverage for identified services prior to receipt
- Successfully working with payers via electronic/telephonic and/or fax communications
- Responsible for verification and investigation of authorization, and referral requirements for patients
- Coordinates and supplies information to the review organization (payer) including medical information and/or letter of medical necessity for determination of benefits
- Collaborates with designated clinical contacts regarding encounters that require escalation to peer-to-peer review
- Communicate with patients, clinical partners, financial counselors, and others as necessary to facilitate authorization process
- Facilitates submission of clean claims and reduction in payer denials by adhering to both organizational and departmental policies and procedures and maintaining departmental productivity and quality goals
- Appropriately prioritizes workload to ensure the most urgent cases are handled in a tat less than 10 minutes
- Completes accurate documentation in both the Auth/Cert and Referral Shells
- Completes notification to all payers via electronic/fax/telephonic means within 24 business hours of service to ensure compliance with Managed Care contractual requirements
- Determines Medicare primacy based on CCHI guidelines
- Determines inpatient Medicare coverage for days exhausted and hospice entitlement
- Ensures timely and accurate insurance authorizations are in place prior to services being rendered
- Follows departmental policies and procedures when necessary, authorization is not obtained prior to service date
- Answers provider, staff, CCHI and patient questions surrounding insurance authorization requirements
- Visit hospitals for high-value cases
- Investigate fraud and unjustified cases
- Business visits for high-cost investigation and negotiations.
Pediatric Resident Attachment
Qatif Central Hospital MOH
Al Qatif, Saudi Arabia
2022.02 - 2022.05
- Conducts daily ward rounds to inpatients
- Performing diagnostic or therapeutic procedures to patients in the field of specialty under the supervision of senior staff (consultant/specialist)
- Carrying out on-call duties in the hospital
- Present cases at team grand round and morning meeting when required
- Attending E.R cases on on calls
- Attending weekly brainstorming activities
- Respond promptly to the request of consultant medical staff and nursing staff to attend any patient within the hospital, and to initiate or advise on treatment as indicated
- Undertake specific medical procedures on pediatric patients within all departments in the hospital as requested by consultants, or in support of nursing and other clinical staff Sitting of intravenous cannula and commencing intravenous infusions, Urinary catheterizations – urethral, Administration of intravenous drugs, ECG, Phlebotomy, and arterial blood gas sampling
- Check and review blood results as directed by consultant or nursing staff
- Prescribe medicines to take home in accordance with consultant instructions and/or protocol
- Comply with the hospital's consent and confidentiality policy
- Participates in the Major Disaster Plan of the hospital, as indicated
- Participate in online system improvement activities, system control activities, and staff development activities.
Intern
Ministry Of Health Saudi Arabia
Jeddah, Saudi Arabia
2019.05 - 2020.06
- Handling Surgery under the supervision of senior consultants Dressing, prescribing medication post O.R Dealing with patient's family
- Chest tubes insertion and removal Clerking Worked well independently and, on a team, to solve problems
- Served as a positive and enthusiastic team player.
- Worked productively with team members to achieve common goals.
- Showed initiative and willingness to take on new challenges.
- Managed time effectively to meet deadlines.
- Used problem-solving skills to resolve challenges and prioritise workload.
- Made positive contributions to team and workplace, consistently exceeding expectations.
- Identified and resolved issues using critical thinking and problem-solving skills.
- Participated in staff meetings to discuss latest developments.
- Shadowed senior team members to develop practical knowledge and gain critical industry-specific skills.
- Used strong work ethic to meet stringent deadlines.
Intern
Al Jeddani Group of Hospitals
Jeddah, Saudi Arabia
2018.05 - 2018.08
- Training at Anesthesia Department helping consultants during surgery observing critical cases maintaining medical reports for post-operative patients
Education
MBBS - Medicine and Surgery
Ibn Sina National College for Medical Studies
Jeddah, Saudi Arabia 2012.09 - 2019.07
MSC - Health Care Management
SBS Swiss Business School
Switzerland 2025.12 -
PG Diploma - Medical Emergency management
Health sciences academy Pakistan
Pakistan 2026.01 - 2027.01
Executive MBA - MBA General Master of Business Administration
Swiss Business School
Switzerland 2025.12 -
Skills
- Project Management
- Ai and digital transformation
- Decision Making
- Complex Problem Solving
- Interpersonal Communication
- Interpretation
- Excellent Oral and Written Communication
- Ability to Learn Quickly
- Time Management
- Customer relationship management systems
- Interpersonal effectiveness
- Technical proficiency
- KPI tracking
Certification
- Scientific research, Ibn-Sina National medical college MAY 2017 — DECEMBER 2017
- BLS, American heart Association JUNE 2018 — JUNE 2018
- ATLS, American heart Association JUNE 2019 — AUGUST 2020
- Microsoft word training, I.T campus Co. AUGUST 2020 — FEBRUARY 2021
- Root Cause Analysis, Ibn-Sina national medical college JULY 2021 — JULY 2021
- IFCE – INSURANCE FOUNDATION PROFESSIONAL EXAM BY (SAMA) DECEMBER 2020
- ANTI-MONEY LAUNDRYING MARCH 2021
- FRAUD AWARENESS – by THOMPSON MARCH 2021
- FINANCIAL CRIME - Saudi Arabia by THOMPSON MARCH 2021
- ILETS by British council (band-8) JANUARY 2020
- Project Management Professional – PMP
- Risk Management course – 2025
- Data Privacy Workshop – 2025
- Artificial Intelligence in healthcare by meta healthcare academy– 2025
- Power – BI and intermediate data workshop by American consulting experts- 2026
- Level 5 diploma in health and social care leadership- 2026
Languages
English
Urdu
Arabic
References
References available upon request
Personal Information
- Date of Birth: 05/25/1991
- City of birth: Jeddah KSA
- Nationality: Pakistani
References
References available upon request.
Timeline
PG Diploma - Medical Emergency management
Health sciences academy Pakistan
2026.01 - 2027.01
MSC - Health Care Management
SBS Swiss Business School
2025.12 -
Executive MBA - MBA General Master of Business Administration
Swiss Business School
2025.12 -
Reimbursement manager for eastern region
TAWUNIYA INSURANCE COMPANY
2024.12 - 2026.05
Pre-Authorization Doctor
TOTAL CARE SAUDI
2022.07 - 2024.01
Pediatric Resident Attachment
Qatif Central Hospital MOH
2022.02 - 2022.05
Approval and Roving Doctor
Gulf-Union Insurance Company
2020.10 - 2022.07
Intern
Ministry Of Health Saudi Arabia
2019.05 - 2020.06
Intern
Al Jeddani Group of Hospitals
2018.05 - 2018.08
MBBS - Medicine and Surgery
Ibn Sina National College for Medical Studies
2012.09 - 2019.07