Muhammad Qais
Riyadh,Saudia Arab
Summary
Experienced Insurance Doctor with strong expertise in medical claims review, eligibility assessment, and policy compliance. Skilled in evaluating medical necessity, identifying discrepancies, and ensuring accurate application of insurance guidelines to support fair and efficient decision-making
Overview
12
12
years of professional experience
1
1
Certification
Work history
Insurance Doctor
Riyadh Hospital
Riyadh, Riyadh Region
2025.05 - Current
- Conducted detailed medical evaluations for insurance claims, ensuring diagnoses, treatments, and procedures aligned with policy and clinical guidelines
- Reviewed patient medical records, laboratory reports, imaging findings, and physicians’ notes to assess medical necessity and claim eligibility.
- Collaborated with treating physicians, hospital billing teams, and insurance coordinators to clarify clinical details and resolve claim discrepancies
- Evaluated pre-authorization and concurrent review requests and provided recommendations based on clinical assessments and company policies
- Participated in quality improvement meetings and contributed to developing review protocols and medical guidelines
INSURENACE DOCTOR
JWAHER SIHATIC MEDICAL COMPLEX
Riyadh
2024.05 - 2025.04
- Approvals, review, and submission of claims.
- Monitored email correspondence, prioritising urgent messages to maintain effective communication channels.
GENERAL PHYSICIAN / INSURANCE CORDINATOR
FAMILY SMILE CLINIC
Riyadh
2021.02 - 2024.05
- Prescribed medication with dosage advice to suit individualized patient needs.
- Discussed symptoms, diagnoses and prognoses with patients and caregivers to support informed medical decisions.
GENERAL PHYSICIAN
RIVER OF HEALTH MEDICAL CENTER
Riyadh
2018.09 - 2021.01
GENERAL PHYSICIAN
BILAD AT TIB POLYCLINIC
Riyadh
2017.08 - 2018.08
MEDICAL CLAIMS AUDITING
SAUDI NEXTCARE
Riyadh
2016.08 - 2017.08
- Evaluated medical records to assess completeness, accuracy and data integrity.
- Prepared and delivered case notes for different individual or team needs.
CLINICAL ATTACHMENT
KING SALMAN HOSPITAL
Riyadh
2015.04 - 2016.04
- Complied with best clinical practice and data confidentiality protocols.
- Handled initial client assessments to create personalised development programmes.
MEDICAL HOUSE OFFICER
ABBASI SHAHEED HOSPITAL
Karachi, Pakistan
2014.01 - 2015.01
- Attended medical rounds and case discussions, actively participating in clinical decision-making processes.
- Diagnosed and treated patients under supervision, contributing to efficient healthcare delivery.
- Responded to medical emergencies, demonstrating quick thinking and effective decision-making.
Education
Bachelor of Medicine & Bachelor of Surgery -
Hebei North University
ChinaHigher Secondary School Certificate -
Pakistan International Collage
RIYADH, KSASecondary School Certificate -
Pakistan International school
RIYADH, KSATahfeez ul Quran -
Skills
- Sound knowledge of medical terminology
- Good command of handling medical equipment
- Good knowledge of Anaesthesiology and Surgery
- Handling approvals, rejections, and submissions
- Microsoft Office
Professional Information
INSURANCE DOCTOR /MEDICAL CODER
Certification
- Basic Life Support (BLS), 11/2013 - 11/2013
- Advanced Cardiovascular Life Support(ACLS), 08/2015 - 08/2015
- CCP-KSA (professional coding) - 2025
Websites, Portfolios and Profiles
https://linkedin.com/in/qais_shujayahoo.com
Languages
1,A1,6,C2,4,B2,6,C2,1,1,1,1
Languages
ENGLISH
ARABIC
URDU
MANDARIN
Timeline
Insurance Doctor
Riyadh Hospital
2025.05 - Current
INSURENACE DOCTOR
JWAHER SIHATIC MEDICAL COMPLEX
2024.05 - 2025.04
GENERAL PHYSICIAN / INSURANCE CORDINATOR
FAMILY SMILE CLINIC
2021.02 - 2024.05
GENERAL PHYSICIAN
RIVER OF HEALTH MEDICAL CENTER
2018.09 - 2021.01
GENERAL PHYSICIAN
BILAD AT TIB POLYCLINIC
2017.08 - 2018.08
MEDICAL CLAIMS AUDITING
SAUDI NEXTCARE
2016.08 - 2017.08
CLINICAL ATTACHMENT
KING SALMAN HOSPITAL
2015.04 - 2016.04
MEDICAL HOUSE OFFICER
ABBASI SHAHEED HOSPITAL
2014.01 - 2015.01
Higher Secondary School Certificate -
Pakistan International Collage
Secondary School Certificate -
Pakistan International school
Bachelor of Medicine & Bachelor of Surgery -
Hebei North University