Afsheen Ghufran
Abu Dhabi
Summary
Skilled insurance doctor with a strong background in medical practice, health insurance, medical billing and auditing, healthcare fraud, waste and abuse detection, and provider relationship management. Decisive and compelling communicator with demonstrated problem-solving, leadership and planning ability.
Overview
18
18
years of professional experience
1
1
Certification
Work History
Senior Officer
National Health Insurance Company – Daman
12.2017 - Current
- Conduct data driven on site audits of healthcare service providers, validating and evaluating accuracy of medical records and related documents of members to assess any discrepancies in billing of services or in regard to justification of procedure(s), yielding financial recoveries.
- Investigation of suspected health insurance fraud, misuse and abuse yielding terminations of insurance contracts, blacklisting of suspected clinicians, regular follow ups with healthcare regulators, judiciary department, and law enforcement agencies which resulted in technical knowledge with respect to relevant regulations and procedures, apart from financial recoveries.
- Ensure business decisions and processes are professionally and confidentially documented.
- Analyzing billing trends and / or statistical provider behavior, comparing with internationally set KPIs and local market benchmarks.
- Extensive involvement in staff development and conduct training to improve technical, insurance and medical skills for team members as well as new joiners, contribute towards technical development, updating and implementation of medical guidelines.
- Coached junior team members, fostering professional growth and improving overall team performance.
General Practitioner
Quratul Ann Maternity Clinic
01.2012 - 12.2014
- Rotational Medical, Surgical, Emergency, Gynecology, and Orthopedics Department Experience.
- Examined patients, documented medical histories, ordered lab tests, x-rays, and other diagnostic procedures, referring patients to specialists where appropriate.
- Assisted in hospitals with limited staff and high patient volume.
- Provided emergency care for acute coronary syndrome and asthma attacks.
- Conducted routine vaginal deliveries and provided pre-natal and post-natal care.
- Assisted in breast feeding techniques and issues.
- Informed patients and families about laboratory diagnostic reports.
- Report notifiable diseases to governmental authorities.
Resident Medical Officer
Farida Maternity Clinic
08.2006 - 04.2007
- Maintaining accurate medical records and patient history.
- Conducting clinical examinations for Gynecology/Obstetric Unit.
- Diagnosing early illness symptoms and prescribing medication changes.
- Identifying chronic cases and referring patients for further prognosis.
- Examining patients' medical history, medication allergies, physical condition, and test results.
- Managing Gynecological and Obstetric Emergencies 24/7.
- Assisting in complicated vaginal deliveries (forceps and breech vaginal deliveries) as well as Caesarian Sections and other Surgical Procedures.
- Discussing Family Planning and Infertility treatment options.
- Educating patients about conditions and treatment options.
- Providing routine and emergency medical care.
- Advising senior physicians and surgeons during assessments and interventions.
- Applied continuous process improvement strategies.
- Completing patient referrals to other medical specialists.
- Training and supervising medical students and residents.
Resident House Officer
Civil Hospital / Lyari General Hospital
08.2005 - 07.2006
- Attending clinical training in Medical Unit and Gynecology/Obstetric department.
- Analyzing test results and information for proper diagnosis.
- Participating in Ward Rounds and Case Presentations.
- Carrying out bed side procedures like N/G Intubations, Urinary Catheterization, and Paracentesis.
- Assisting senior consultants during Thoracentesis and Endoscopic procedures.
- Learning and conducting normal vaginal deliveries.
- Assisting surgical procedures related to obstetrics and gynecology.
- Explaining prescribed procedures and discussing test results with patients and families.
- Attending outpatient clinics and maintaining confidentiality.
Education
Bachelor of Medicine, Bachelor of Surgery (MBBS) -
Dow University of Health Sciences
Karachi, Pakistan01.2005
Skills
- Medical Practice
- Fraud ,Waste & Abuse Detection
- Trained to work with tools required for auditing (eg, 3M coder, DRG tool, Audit Management & Tracking system etc)
- Data Analytics
- Market Analysis
- Data-Driven Decision-Making
- Effective Report Writing using IRAC method
- Sound legal knowledge pertaining to auditing of providers in UAE market
- Communication, negotiation, presentation and interpersonal skills
- Ability to operate effectively with people at all levels of the business
Languages
English
Urdu
Hindi
Medical Licensing
- Dubai Health Authority (DHA), 2017-2018, UAE
- Pakistan Medical and Dental Council (PMDC), Up to date, Pakistan
Courses Training
- Fraud & Abuse Identification Training
- Negotiating Skills –The Powerful Negotiator
- Creative Problem Solving & Decision Making
- Communication Skills
- MS Word & MS Excel
Internship
- Gynecology & Obstetrics, 6 months
- Medicine (General), 6 months
Personal Information
Date of Birth: 06/22/82
Accomplishments
Recognized and appreciated for being a key team player and awarded the 'Star of the month' twice with in last 18 months.
Certification
Certified Healthcare Auditor (CHA)
American Institute of Healthcare Compliance, Inc (AIHC)
Timeline
Senior Officer
National Health Insurance Company – Daman
12.2017 - Current
General Practitioner
Quratul Ann Maternity Clinic
01.2012 - 12.2014
Resident Medical Officer
Farida Maternity Clinic
08.2006 - 04.2007
Resident House Officer
Civil Hospital / Lyari General Hospital
08.2005 - 07.2006
Bachelor of Medicine, Bachelor of Surgery (MBBS) -
Dow University of Health Sciences
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