Dr DIVYA YEMULA
Dubai,United Arab Emirates
Summary
Motivated and experience Medical Insurance Professional with medical background with good years of experience, recognized for assessing operational needs and developing solutions to save costs, improve revenues and drive customer satisfaction. Resourceful and well-organized with excellent leadership and team-building record.
Overview
11
11
years of professional experience
Work history
Case manager
Dr Sulaiman Habib Group
Dubai
11.2023 - Current
- Regularly auditing the claims and clinician documentation and training the staff as per guidelines.
- Conducting meetings with treating physicians on Clinical documentation improvement as per medical necessity.
- Reviewing the claims data for FWA to avoid unnecessary rejections from payers.
- Training the Medical coding staff on Resubmission and understanding the clinician orders to specific condition to justify the query raised by payers.
- Attending recovery requests received by payers and providing them with correct information in justified cases.
- Working on Reconciliation files and attending the meetings and finalizing the reconciliations with Payers/TPA’s for eligible cases.
Medical claims admin
Al Sagr National Insurance Company
Dubai
10.2020 - 10.2023
- Evaluating IP approval requests received from TPA's and issuing approvals based on policy terms. Raising queries wherever sufficient information is not available. Maintaining TAT for all approvals
- Co-ordinating with TPA's for pending OP approvals requested by clients and members.
- Attending calls from clients, members, brokers and all other branches for their queries related to approvals and policy related issues. Resolving the complaints based on requirements.
- Processing direct billing claims for all the TPA's and forwarding the EFT's to accounts for payment.
- Giving premium quotation for group and individual new and renewal policies based on member's medical conditions and severity of their health conditions.
- Handling all DHA, ISHAD and IA complaints and updating them with justification for rejection and following up with client.
Medical Claims officer &Medical coding analyzer
Pentacare Medical services Pvt Ltd
Dubai
01.2017 - 06.2020
- Auditing of E-claims (In-patient and Out-patient) as per the D.H.A/H.A.A.D. regulations and policy coverage.
- In charge of auditing Government Hospital claims within timeline.
- Analyze claims for fraud and abuse (Up coding, Unbundling of CPTs, DRG discrepancy, Over- investigations, etc.) and report it to the Head of Claims. Auditing IP and associated OP Reimbursement claims (International & UAE) as per policy terms & conditions.
- Co-ordinating with teams for further required documents.
- Answering calls for Reimbursement queries and updating the details with clients.
- Auditing of GOP (Guarantee of payment) claims.
- Communicate with the Insurance In-charge at the provider levels regarding discrepancies in billing, documentation, etc.
- Accomplish organization goals by accepting ownership for accomplishing new and different requests. Exploring opportunities to add value to job accomplishments.
Medical officer
Infinite Med tech solutions Pvt Ltd
Hyderabad, India
04.2015 - 10.2015
- Medical scrutiny of Middle East member Reimbursement(OP & IP), E – claims
- Application of Medical coding knowledge in processing E-claims (CPT/HCPCS/ICD/Physician codes).
- Raise necessary queries for short fall documents to complete claim processing.
- Medical Auditing of Middle East health claims.
- Handling a Team of executives where their Attendance and Leaves are reviewed from my end.
- Educate the executives on updated medical policies/claim processing/clarify doubts on Medical part-Deductibles/co-pay etc.
- Handling pre approvals upon receiving request from providers. Maintaining good communication with providers.
- Seek Clarification/ additional information from providers to give pre approvals on case to case basis.
- Assist customer relationship executives for replies from Member relevant to member Reimbursement claims.
Medical Claims Officer
Dedicated Health Care Services (TPA)
Hyderabad, India
02.2014 - 03.2015
- Corporate (Group) and individual (Retail) claims Scrutiny-Paper claims. Presentations given in Corporates regarding health policy coverage benefits.
- Guidance on Pre-authorization to hospitals
- Clarification of queries encountered from members on Reimbursement claims
- Conduct investigation in person in Network and Non- Network Hospitals in case of suspected claims involved to understand the genuinity.
Education
MSC BIOMEDICAL SCIENCE -
University of East London
London, United KingdomCPC AAPC Certified coder -
Hyderabad, India
Hyderabad, IndiaBACHELOR OF HOMEO MEDICINE AND SURGERY -
JSPS Homeo medical college
Hyderabad, IndiaSkills
- Good organizational skills in managing accurately and efficiently meeting self and Team targets and managing within assigned TAT
- Efficient in time management and attention to detail
- Excellent numeric skills
- Hands on working experience in MS Office (MS Word, Excel, Power point)
- Ability to work on taking ownership and quick in problem solving and in taking appropriate decisions and deliver work under pressure as well
- Perform well individually and as team
- Punctual and can adapt to flexible working hours
- Strong and effective communication skills
- Client assessment
- Case management
Languages
Telugu
Hindi
English
Personal Information
- Date of birth: 03/05/82
- Nationality: Indian
- Marital status: Married
Custom
I hereby declare that the above-mentioned information is correct up to my knowledge and I bear the responsibility for the correctness of the above-mentioned particulars.
Timeline
Case manager
Dr Sulaiman Habib Group
11.2023 - Current
Medical claims admin
Al Sagr National Insurance Company
10.2020 - 10.2023
Medical Claims officer &Medical coding analyzer
Pentacare Medical services Pvt Ltd
01.2017 - 06.2020
Medical officer
Infinite Med tech solutions Pvt Ltd
04.2015 - 10.2015
Medical Claims Officer
Dedicated Health Care Services (TPA)
02.2014 - 03.2015
MSC BIOMEDICAL SCIENCE -
University of East London
CPC AAPC Certified coder -
Hyderabad, India
BACHELOR OF HOMEO MEDICINE AND SURGERY -
JSPS Homeo medical college
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