- SQL
Ahmed Ramadan
Medical Claims Review And Operations Supervisor
Abu Dhabi,UAE
Summary
Versatile Operations Supervisor successful at taking on routine and complex business challenges with resourceful and creative approach. Recognized as driven, dedicated and hardworking leader with history of streamlining operations and increasing results. Talented Operations Supervisor well-versed in multifaceted business and employee management to achieve targeted results. Decisive leader and strategic problem solver with exceptional communication and foresight. Organized and personnel-focused strategic problem-solver with innovative solutions to uncharted problems. Adaptable Office Administrator with [Number] years of background in [Skill], [Skill] and [Area of expertise]. Willing to take on new tasks with enthusiasm and considered valuable and gifted team player. Dynamic administrative professional and leader with [Number]+ years of experience playing key role in attaining daily objectives and long-term goals across diverse office platforms. Excel in timely and accurate processing of accounts payable and receivable and applying advanced analytical acumen. Strongly committed to raising productivity and service quality via strategic planning and allocation of resources as well as implementation of process improvements. Skilled receptionist and liaison with superior communication, computer, support and organizational skills.
Overview
12
12
years of professional experience
7
7
years of post-secondary education
12
12
Certifications
Work History
Medical Claims Review and Operations Supervisor
Daman, National Health Insurance
Abu Dhabi, UAE
05.2016 - Current
- Motivated and trained employees to maximize team productivity.
- Enhanced operational performance and reduced labor expenses by developing and optimizing standard practices.
- Managed internal operational standards and productivity targets.
- Developed and deepened relationships with customers, vendors and internal stakeholders.
- Evaluated team member performance and productivity, provided feedback and implemented corrective actions.
- Led associate focus groups and meetings to obtain suggestions, address concerns or issues and foster positive relations among team members and management.
- Conducted root cause analysis in deficient areas to identify and resolve issues.
- Analyzed department metrics and performance and reported findings to management.
- Encouraged and promoted ideas aligned to business needs and benefits.
- Collected customer feedback and made business adjustments to improve retention and satisfaction.
- Participated in continuous improvement by generating suggestions, engaging in problem-solving activities to support teamwork.
- Identified issues, analyzed information and provided solutions to problems.
- Resolved problems, improved operations and provided exceptional service.
- Used critical thinking to break down problems, evaluate solutions and make decisions.
- Monitored and guided revenue cycle operations.
- Reviewed and analyzed suspicious and potentially fraudulent insurance claims.
- Analyzed information gathered by investigation and report findings and recommendations.
- Advanced productivity KPIs to achieve key business goals and objectives.
- Reduced process bottlenecks by training and coaching employees on practices, procedures and performance strategies.
- Identified procedure or process changes required to improve performance and productivity.• Handling Daman’s claims (Submission, Resubmission & Reconciliation) processing team •
- Reviewing claims records for compliance with national & international medical coding, billing, and insurance guidelines • Monitor team’s daily target, processing quality and ensures claims processing and reporting timelines.
- Handling providers queries (Replying queries and meeting providers to resolve claims and billing related issues)
- Prepare, analyses, and disseminates claims reports inquired by higher management and other departments.
- Collaborates with all levels of stakeholders in the development, implementation, and evaluation of new projects and programs.
- Auditing, reviewing, and reporting medical claims to finance department.
- Handling different automation, process, and regulator enhancement projects
- Monitor team members’ performance and provide them with the required training to improve their technical, insurance and medical skills and knowledge. • Consistently, efficiently, and effectively work on achieving the daily targets.
- Ensure accurate application of contractual prices and discounts, schedule of benefits, and adherence to claims submission protocols.
- Aware of DOH unified lists and denial codes.
- Liaise with Receiving Unit, Quality Unit and Medical Investigation Unit for provider related issues that needs investigation of any pending/absence of payments.
- Liaise with network department for missing prices in the contracts or any other contracts related issues in order to keep track. • Liaise with IT for related issues which different supervisors/teams may come across.
- Medical evaluation of claims i.e. rejection and acceptance of services given by providers on basis of medical knowledge
- Maintaining track of daily distribution of claims to teams
- Continuously work on improving relevant functional and personal competencies.
- Ensure that the team delivers high quality customer service and always respects medical and work ethics.
- Coordinated innovative strategies to accomplish marketing objectives and boost long-term profitability.
- Partnered with business teams and IT personnel to align project goals with business strategy and define project milestones.
- Created reports and presentations detailing business development activities.
- Followed up on potentially fraudulent claims initiated by claims representatives.
- Managed large volume of medical claims on daily basis.
- Maintained knowledge of benefits claim processing, claims principles, medical terminology and procedures and HIPAA regulations.
- Coordinated with contracting department to resolve payer issues.
- Communicated verification and authorization status updates with all company departments to facilitate decision-making for patient admissions and insurance coverage.
Senior Medical Claims Processor
Daman, National health insurance company
Abu Dhabi
04.2013 - 05.2014
- Exceeded goals through effective task prioritization and great work ethic.
- Adhered to social distancing protocols and wore mask or face shield.
- Created plans and communicated deadlines to complete projects on time.
- Offered friendly and efficient service to customers, handled challenging situations with ease.
- Working as team leader managing team, distribution of work and time managing. •
- Auditing, reporting claims and developing process tools and auditing criteria.
- Preparing reports for managements and other departments regarding providers’ behavior, processors & workflow.
- Sharing in different projects in the company as claims representative (planning, preparing reports, data analysis, communication &documentation).
- Training new joiners or old staff on new instructions, rules, or system developments.
- Monitoring and evaluating performances of employees using different tools with focus on quality.
- Ensure that business decisions and processes are documented in a professional way.
Medical Claims Processor
Daman, National health Insurance Company
Abu Dhabi, UAE
07.2008 - 03.2013
- Followed up on potentially fraudulent claims initiated by claims representatives.
- Managed large volume of medical claims on daily basis.
- Reviewed provider coding information to report services and verify correctness.
- Used administrative guidelines as resource or to answer questions when processing medical claims.
- Processing and evaluation all types of claims
- Define the final sum that must be paid on the claim by implementing the fee schedules and the benefit schedules (Aware of HAAD unified lists and denial codes)
- Evaluates and develop tools for a proper evaluating of the claims and management of cases while applying the wording of the policy and the schedule of benefit
- Ensures that the medical ethics are respected all the time during processing of the claims
- Proper encoding of the services.
Graduate Teaching Assistant
October 6 University
Cairo, Egypt
09.2007 - 05.2008
- Documented attendance and completed assignments to maintain full class and student records.
- Checked assignments, proctored tests and provided grades according to university standards.
- Oversaw classes of up to 35 students in Organic chemestry
- Taught principles of organic chemistry and technique of performing some experiments college-level courses for over 35 students.
Education
MBA - Health Care Management
Cardiff Metropolitan University
Cardiff, Wales, UK 06.2021 - Current
Bachelor of Pharmaceutical Sciences -
October 6 University
Cairo, Egypt 09.2002 - 07.2007
Certified Project Management Professional (PMP) - Project Management
American Project Management Institute
USA 01.2020 - 12.2020
Skills
- Lage volume (3 Million/Month)Claims handling
- Medical histories and vital statistics
- Claims investigation and research
- Medical billing and coding
- Claims reviewing
- Process tactics development
- Knowledgeable in [Software]
- Insurance industry experience
- Excellent administrative abilities
- Insurance claims processing
- SQL & SAS Data analysis proficiency
- Business Process Analysis
- Process Development
- Advanced retouching
- Data file transferring
- Process flow analysis
- Quality assurance
Software
- SAS Enterprise
- Microsoft Power PI
- MedNext, Documentum (Claims Processing Tools)
- Microsoft Office
- Oracle Business Intelligence Discover Desktop (Data analysis and reporting Tool)
Certification
- Certified [Financial Crime Compliance], ICA
Accomplishments
• Handling Daman’s OP claims +3 Million/Month (Submission, Resubmission & Reconciliation) processing team (28 staff)
• Collaborated with other Daman departments and DOH in the development of ABM COVID 19 Preventive, Vaccination, isolation and quarantine billing rules.
• Successful using of forecasting techniques to predict inventory during Covid pandemic
• Leading Claims automation initiatives project (Automation rate 80%) with 99.7% accuracy.
• Represent Claims department in design and deployment of inhouse new Daman Insurance Core System (OHI)
• Establishing Providers Claims queries team, design the process and the KPIs
• Leading Remittance Advices generation, transactions, and queries process “re-structuring and enhancement project”
• Represent Daman Claims department in many DOH driven programs (Population at Risk program and Mobile clinics) to develop the appropriate billing rules
Timeline
- Certified [Financial Crime Compliance], ICA
02-2022
- ICD-10 & CPT4 (2018) Medical Coding Training, DOH
08-2021
MBA - Health Care Management
Cardiff Metropolitan University
06.2021 - Current
- Certified PMP, American Project Management Institute
12-2020
Certified Project Management Professional (PMP) - Project Management
American Project Management Institute
01.2020 - 12.2020
- Transformational Leadership Training
12-2019
- Data Analysis Techniques Training
09-2018
- SAS Programming Enterprise Guide Training
11-2016
- Setting & Managing Targets Training
09-2016
Medical Claims Review and Operations Supervisor
Daman, National Health Insurance
05.2016 - Current
- Managing Upwards with Influence Training
04-2016
- MS Excel Advanced Training
09-2015
- ICD10 & CPT Medical Coding (CPC & COC)Training Course
04-2015
Senior Medical Claims Processor
Daman, National health insurance company
04.2013 - 05.2014
- E&M coding HAAD educational course
11-2010
- Principles of insurance Training, Emirates Institute for Banking & Financial Studies (EIBFS)
10-2010
Medical Claims Processor
Daman, National health Insurance Company
07.2008 - 03.2013
Graduate Teaching Assistant
October 6 University
09.2007 - 05.2008
Bachelor of Pharmaceutical Sciences -
October 6 University
09.2002 - 07.2007