DR B MOHAMED SAMEER BUHARI BHMS, CPC

Roles & Responsibilities:
Evaluate Medical Approvals for outpatient and inpatient services based on Treatment Plans, Medical Justification, and Policy Terms and Conditions.
Approve or Deny Medical Approvals according to Policy Terms and Conditions.
Assess the severity of IP-DRG and CPT codes according to Coding Guidelines and Treatment Management.
Follow established protocols to process Prior Authorization requests and Claims.
Adhere to Turnaround Time (TAT) for approvals and denials as per DHA protocols.
Analyze Treatment Plans and ask healthcare providers relevant questions based on the Diagnosis.
Respond to Client and Broker inquiries related to Approvals, Policy Benefits, Denials, etc., via phone calls, WhatsApp, and Email.
Coordinate Home-Country Treatments with different providers as per policy.
Strictly follow the Authorization Limit given by payers and seek approval from payers beyond the limit.
Ensure Client Satisfaction by resolving issues timely and offering clear explanations related to denials.
Provide Manual Approvals for Non-network and other Northern Emirates providers.
Claim entry for verbal and paper claims.
Additional roles:
Maintain regular communication with payers to submit Claims Utilization reports, COVID reports, PSP reports, etc.
Monitoring all OP approvals and denials and solving issues related to it.
Monitoring approvals and solving issues for premium clients with special attention.
Coordination with the Network team, and Business development team for troubleshooting issues and addition of providers.
Coordination with the Finance team and payers to avail payments on a timely basis.
Attending regular meetings with the CEO and other Senior claims Managers to discuss client satisfaction, Efficient claims Management, Medical services abuse, and Cost Control.
Invest Strong focus and efforts for Smooth Renewal of Policies with Clients.

worked as an Covid medical officer for 18 months . I was responsible for patient's admission and discharge , stabilizing the hypoxic patients , obtaining expert opinions , oxygen management , conducting follow-up rounds with Senior Consultants . I was posted in different units like oupatient wards , Inpatient wards , Special wards, Triage , Icu.

Worked in KIMS Hospitals for 1 Year as a Duty medical officer in the pre-operative ward, post-operative ward, general ward, medical records department, and also in case summary summarization.