MOHAMMED SHAKEEL AHMED
Al-Ahsa
Summary
Experienced Claims Auditor with a proven record of success examining insurance claims for accuracy and compliance. Skilled in resolving discrepancies and optimizing processes.
Overview
3
3
Languages
25
25
years of professional experience
Work History
Medical Claims Audit Supervisor (RCM)
Al Moosa Specialist Hospital
12.2017 - Current
- In-Patient billing for accuracy in accordance to financial mythologies and perform auditing for cost-effectiveness
- Monitor In-Patient Discharges (Aramco, Insurance Companies, Government Social Insurance, Ministry of Health and Re-imbursement) to assure that bills have been generated
- Notifying the team members of the potential mistakes in auditing the quality score for each individual member
- Finalize all invoices to be delivered to finance in a timely manner within the billing month of admission/discharge
- Finalize cash invoice on real time billing and finalize audited bills before patient discharge
- Preparing Monthly Audit meetings with the RCM Director for solutions to the gaps identified during Audit
- Providing Necessary updates on coding guidelines for the smooth process of the claims, Approval and resubmission
- Responsible meeting department productivity and quality goals
- Cooperate with other Supervisors and Managers
- Implement options to meet individual health needs through communications and available resources to provide the right health care, at the right time, in the right setting by accurate billing
- Use available codes resources billing purposes upon utilization of services for cost effective patient care
- Follow up In-Patient Admissions and Discharges bills on a daily basis and provide the right billing to suggest charged services and fasten TAT for billing
- Close communication with approval Department and ADT for effective billing and claim attachment
- Ensures confidentiality of all patient record and derived data.
- Trained and mentored staff to perform the best audit practices and improve quality standards.
- Optimized team structure, aligning responsibilities with performance measures and metrics to establish audit success.
- Contributed to audit planning, testing and review of audit programs to determine appropriateness for the company.
- Identified deficiencies and recommended use of revised methodologies to improve audit applications.
- Attended and completed regular mandatory audit and accounting training to apply best audit practices.
- Supervised independent audits to monitor growth and productivity.
- Introduced an automated audit system to generate cost savings.
- Assessed data insights to advise on performance gaps and opportunities.
- Evaluated internal operating processes and reallocated staff resources to maintain audit quality.
- Allocated resources and hired individuals with matching skills and potential.
- Applied Six Sigma methodology to evaluate and make informed process improvement recommendations.
- Designed and executed policies and procedures to align with audit requirements and regulations.
- Supervised and guided 20employees during audits to safeguard accuracy.
Medical Claims Review Officer
SAICO-Saudi Arabian Co Operative Insurance Company
01.2012 - 09.2013
- Responsible for reviewing claims submitted to ensure that proper guidelines have been followed
- Aware twice by company for Putting up excellent work
- Verifying eligibility
- Maintaining & looking into the history of past benefits
- Identifying duplicate charges
- Checking approvals & second opinion
- Calculating payable benefits
- Reviewing claims as per the agreed price list
- Negotiated rates with providers and Health Partners administration
Medical Claims Processing Supervisor
SAICO-Saudi Arabian Co Operative Insurance Company
01.2008 - 12.2011
- Audit claim handling processes
- Recommend and coordinate needed changes based on process analysis
- Develop, analyze, and prepare reports to submit to management on team performance
- Supervise staff in accordance with company policies and procedures
- Conduct interviews, hire new staff, and provide employee orientation
- Track employee goals and conduct employee performance reviews
- Responsible for staff scheduling to include: employee vacations, employee breaks, and back-up for absent employees
- Pursuing providers to arrange their bills in a way facilitating the process of new projects of E-claims
Medical Claims Processor
SAICO-Saudi Arabian Co Operative Insurance Company
01.2008 - 12.2010
- Reimbursement Claims, Provider Claims Riyadh, Adjudicate and process Claims within agreed company SLA, clear to zero, in accordance with policy benefits to facilitate the company achieving its loss ratio target
- Operate within and meet conditions of company service standards, clear to zero, to guarantee customer satisfaction and retention
- Contribute to team and departmental productivity targets so that agreed SLA is achieved and a high level of customer service is provided
- Processing 150 Claims both in-patient and out-patient claims according to policy terms and conditions;
- Expand medical knowledge through claims processing
- Aware twice by company for putting up excellent work Verifying eligibility
- Processing claims as per agreed price list, discounts & as per policy deductible or co-insurance
- Processed medical and dental claims, referrals, encounters, eye and prescription claims
- Implementation of medical claims processes, reconciliation protocols and to communicate & clarify to clients, providers & intermediaries.
- Escalated critical claims or complex situations to supervisor for review.
- Carried out administrative tasks by communicating with clients, distributing mail, and scanning documents.
Charge Nurse
PHC Center -Royal Commision For Jubail
01.2005 - 01.2008
- Built and maintained an excellent rapport with patients and loved ones.
- Collaborated with multidisciplinary healthcare specialists to devise, implement and modify plans of care defining patient outcome goals.
- Determined and implemented nursing standards and structures for better patient care practices.
- Communicated with external departments to facilitate critical patient admissions.
Staff Nurse
King Khalid General Hospital -MOH
01.2002 - 01.2005
- Improved service delivery by demonstrating clinical leadership and best practices.
- Supporting patients with critical conditions, planning and implementing targeted strategies for optimal recovery outcomes.
Education
MBA - Health Care Management
MANIPAL UNIVERSITY (MAHE)
INDIA10.2026
Revenue Cycle, Billing, And Coding (JOHNS HOPKINS) - Revenue Cycle, Billing, And Coding
COURSERA
SAUDI ARABIA07.2026
Lean SIX SIGMA Yellow Belt -
Al Moosa Specialist Hospital
SAUDI ARABIA07-2019
C.M.R.S -Certified Medical reimbursement Specialist -
Americal Medical Billing Association-AMBA
AMERICA04-2019
Trained in Medical Billing and Coding -
Aldos Institute
INDIA02-2017
IFCE- Certificate - SAMA Certified (A)
Institute of Banking (IOB)
SAUDI ARABIA09-2013
Bachelor Of Commerce- B.com -
GITHAM UNIVERSITY
INDIA05-2013
Trained Nurses Certificate - General Nursing
Osmania General Hospital
INDIA06-1993
Skills
- Billing and Auditing - Expert
- Team Leader - Expert
- Investigative Skills - Expert
- Analytical Thinking - Expert
- Problem Solving - Expert
- Attention to Detail - Expert
- Risk management - Expert
Languages
English - Very Good
Arabic - Very Good
Hindi - Native Speaker
Timeline
Medical Claims Audit Supervisor (RCM)
Al Moosa Specialist Hospital
12.2017 - Current
Medical Claims Review Officer
SAICO-Saudi Arabian Co Operative Insurance Company
01.2012 - 09.2013
Medical Claims Processor
SAICO-Saudi Arabian Co Operative Insurance Company
01.2008 - 12.2010
Medical Claims Processing Supervisor
SAICO-Saudi Arabian Co Operative Insurance Company
01.2008 - 12.2011
Charge Nurse
PHC Center -Royal Commision For Jubail
01.2005 - 01.2008
Staff Nurse
King Khalid General Hospital -MOH
01.2002 - 01.2005
Revenue Cycle, Billing, And Coding (JOHNS HOPKINS) - Revenue Cycle, Billing, And Coding
COURSERA
MBA - Health Care Management
MANIPAL UNIVERSITY (MAHE)
Lean SIX SIGMA Yellow Belt -
Al Moosa Specialist Hospital
C.M.R.S -Certified Medical reimbursement Specialist -
Americal Medical Billing Association-AMBA
Trained in Medical Billing and Coding -
Aldos Institute
IFCE- Certificate - SAMA Certified (A)
Institute of Banking (IOB)
Bachelor Of Commerce- B.com -
GITHAM UNIVERSITY
Trained Nurses Certificate - General Nursing
Osmania General Hospital