Muhammad Naveed Arshad Arshad
Riyadh
Summary
Experienced insurance professional with eleven years of successful career assessing medical insurance claims, Approvals & business center RCM. Accessing liabilities upto negotiations and settlements. Detail-oriented, observant and knowledgeable with excellent interpersonal and documentation skills. Efficiently handle high case volumes with accuracy and care.
Overview
12
12
years of professional experience
Work History
Quality and Audit senior Analyst FWA claims
Cigna Worldwide insurance company
Riyadh
10.2023 - Current
- TPA quarterly Audit on paid claims to providers . Review of medical guidelines and identifying trends of FWA claims inclusive of unbundled,overcharging and unnecessary medical services .
- Reimbursement claims review and member investigations with statement of facts .
- Review of utilization and frequency in member calims and identification of overpayment claims through data mining.
- Review of high dollar Inpateint claims and directing TPA for onsite review of case and with roving reports.
Senior Medical Auditor TPA Quality and Operations
Buruj cooperative Insurance Company
Riyadh
09.2022 - 08.2023
- Based payment or denials of medical claims upon well-established criteria for claims processing.
- Oversaw regulatory and strategic initiatives to ensure accuracy of medical claims.
- Performed audits of operational and financial areas to check compliance.
- Maintained accurate accounts for cash, fixed assets and other transactions.
- Presented audit results to management teams, delivering information in non-technical terms for easy understanding.
- Managed and trained team members to enhance audit department performance and increase operational efficiency.
Senior Medical Claims Auditor
Saudi NextCare Allianz Partners
Riyadh, Saudi Arabia
11.2019 - 08.2022
- Accurately processed large volume of medical claims every shift.
- Evaluated pending claims to identify and resolve problems blocking auto-adjudication.
- Inputted data into the system, maintaining accuracy of provider coding information and reported services.
- Based payment or denials of medical claims upon well-established criteria for claims processing.
- Used contract notes and processing manual to correctly apply group-specific classifications to claims.
- Adhered to company and insurance client's guidelines in claims processes, estimate writing and claim closures.
- Reduced loss ratios through fair and prompt processing of claims.
- Assessed insurance claims and reviewed eligibility information for members to determine if payments had been properly made.
- Prioritized daily tasks to complete workloads within department's expected timeframe.
- Analyzed claims processing errors, gleaning information to determine origin of issues and initiated corrective action.
- Promoted cost containment processes by using data mining methods and extensive audits.
- Reviewed, evaluated and adjusted claims to promote fair and prompt settlement.
- Paid and processed claims within designated authority level.
- Completed required investigations on referred files within established timeframes.
- Verified and analyzed claims settlement data to ensure validity.
- Double-checked and reviewed documentation for denied and accepted insurance claims.
Medical Claims Manager
National Blood & Cancer Hospital Riyadh
Riyadh, Saudi Arabia
06.2019 - 10.2019
- Motivated team members to maintain targeted turnaround time to obtain processing goals.
- Managed team members effectively to meet high production standards with accurate results.
- Monitored objectives to determine effectiveness of workflows, facilitating training and mentoring for improvement.
- Reviewed policies to determine appropriate levels of coverage and assist with approval or denial decisions.
- Drafted statement of loss to summarize damages, payments and underlying policy coverage.
Medical pre.authorozatio specialist
Saico .Cigna Global KSA
Riyadh, Saudi Arabia
11.2014 - 05.2019
- Determined insurance coverage levels and restrictions by thoroughly examining claims forms and associated records.
- Reviewed policies to determine appropriate levels of coverage and assist with approval or denial decisions.
- Delivered exceptional customer service to clients by communicating information and actively listening to concerns.
- Communicated with reinsurance brokers to obtain claim information for processing.
- Gathered and documented evidence to support court proceedings.
- Provided patient diagnosis, test evaluation and treatment under strict time constraints.
- Examined patients and recorded medical histories to use in health assessments and help determine conditions.
- Established and maintained relationships with specialists to support patient referrals.
- Referred patients with serious medical conditions and emergencies to hospital for immediate care.
- Evaluated health history and genetic information to recommend preventive healthcare.
- Collaborated closely with fellow medical team members to share knowledge and discuss best courses for treatment.
General Dentist
Al-Wedam medical center
Riyadh, Saudi Arabia
11.2013 - 10.2014
- Analyzed X-rays and reviewed patients' health backgrounds to devise appropriate treatment course.
- Examined patients' teeth, gums and oral tissue to identify and diagnose conditions.
- Designed and fitted patients with dentures, bridges and other prosthodontic dental appliances.
Education
IFCE - Insurance
SAMA
03.2016
Bachelor of dental surgery and medicine - Dentistry
Jinnah Medical And Dental College University
Karachi Pakistan05.2011
Intermediate - Biological and Physical Sciences
Pakistan International School Riyadh
Saudiarabia02.2005
ALMI & CERT FLMI -
LOMA Life Office Management Association
LOMA USASkills
- Regulatory Compliance
- Complex Problem Solving
- Verbal and Written Communication
- Case Presentation
- Claims Evaluation
- Claim Validity Determination
- Insurance Claims Management
- Staff Management
- Insurance Claims Management
- Staff Management
Timeline
Quality and Audit senior Analyst FWA claims
Cigna Worldwide insurance company
10.2023 - Current
Senior Medical Auditor TPA Quality and Operations
Buruj cooperative Insurance Company
09.2022 - 08.2023
Senior Medical Claims Auditor
Saudi NextCare Allianz Partners
11.2019 - 08.2022
Medical Claims Manager
National Blood & Cancer Hospital Riyadh
06.2019 - 10.2019
Medical pre.authorozatio specialist
Saico .Cigna Global KSA
11.2014 - 05.2019
General Dentist
Al-Wedam medical center
11.2013 - 10.2014
IFCE - Insurance
SAMA
Bachelor of dental surgery and medicine - Dentistry
Jinnah Medical And Dental College University
Intermediate - Biological and Physical Sciences
Pakistan International School Riyadh
ALMI & CERT FLMI -
LOMA Life Office Management Association