AWS BI
Dr.Mohamed Aldesouky
HealthCare Insurance Manager
Dubai
Summary
Versatile Senior Manager specializing in "HealthCare Insurance / healthcare claims management" and skilled at planning, implementing and overseeing key improvements to drive business growth and efficiency. History of cultivating an open culture with free exchange of information. Pursuing new professional challenges with a growth-oriented company.
Overview
22
22
years of professional experience
31
31
years of post-secondary education
2
2
Certifications
4
4
Languages
Work History
Regional Healthcare Manager
AXA-Gulf
Dubai
12.2019 - Current
- Drove operational improvements which resulted in savings and improved profit margins.
- Manage Clinical Governance Team.
- Developed and initiated projects, managed costs and monitored performance.
- Manager Providers Audit Team.
- Provided fiduciary oversight to remain within budget constraints, recommending project adjustments where necessary.
- Manage Fraud Waste and Abuse Team.
- Maintained compliance with regulatory parameters in complex projects with overlapping policies.
- Manage Health Care Data Science Team.
- Provided detailed technical and operational direction in project challenges, consistently meeting deliverables according to deadlines.
- Lead HealthCare cost containment initiatives and committee .
- Lead Key Account management committee to manage high risk policies utilization.
- Lead Risk Assessment Committee.
- Lead management of Mal-practice cases.
- Manage regional audit projects.
- Manage audit campaigns projects.
- manage System Automation Projects through applying the technical and medical rules- transmit audits outcomes into algorithms that insure payment integrity and build system enabled FWA shield.
- Maintain processes and SOPs compliance to diverse regional regulators.
- Health care providers negotiations , tackling financial disputes under recoveries, volume rebates, reconciliations and over payment.
- Healthcare insurance representative in regulator summits and meetings discussing strategic drivers .
- Lead the data science team to build, maintain and enhance the BI system .
- Provider directions and algorithms for creating various BI tools and data extracting dashboard that support bossiness decisions, audit capabilities and bossiness monitoring.
- Monitored company utilization to report revenue levels .
- Actively listened to customers, handled concerns quickly and escalated major issues to assigned stakeholder.
- Developed and implemented performance improvement strategies and plans to promote continuous improvement.
Operations Support Specialist
NEXtCARE- Allianz
Dubai
07.2016 - 11.2019
- Collaborated with operations team to provide excellent customer service and foster positive work environment.
- Participated in operations team meetings to coordinate and assign project management tasks.
- Conducted regular quality reviews of business data and processes to identify discrepancies and formulate solutions.
- Prevented and minimized processing errors by analyzing trends and implementing feedback from managers.
- Analyzed and evaluated operational issues and determined cost-effective solutions.
- Coordinated with vendors, customers and internal departments to understand, monitor and communicate changes to workflows.
- Evaluated staff performance and provided coaching to address inefficiencies.
- Supported creation of detailed, technical audit models to value potential leakages and targeted corrections and recoveries.
- Established calculator algorithm for operational reserves based on diverse plat forms performance.
- Monitoring and Reporting of governmental insurance plan.
- Liaise with account manager to report potential loss ratios, communicate the utilization to the clients and work on effective portfolio management plans.
- Implement Regional Business Units Visits and Audits, Generate relevant regional audit reports with findings and recommendations for processes enhancement and setups corrections.
Precertification Manager - Critical Funds Manager
NEXtCARE- Allianz
Cairo
01.2016 - 07.2017
- Developed and implemented performance improvement strategies and plans to promote continuous improvement.
- Shifted paper claims cycle in to paperless work flow.
- Improved TAT in diverse processes to meet maximum efficiency and effectiveness.
- Promoted Automated clients response.
- Completed paperwork, recognizing discrepancies and promptly addressing for resolution.
- Received and processed outstanding into inventory management system.
- Offered friendly and efficient service to customers, handled challenging situations with ease.
Healthcare Insurance Precertification Manager
Alhly Medical TPA
Cairo
01.2012 - 01.2016
- Implemented cost-saving initiatives that addressed long-standing problems.
- Worked to maintain outstanding attendance record, consistently arriving to work ready to start immediately.
- Maintained energy and enthusiasm in fast-paced environment.
- Used Microsoft Office and other software tools to create monitoring dashboards and other communications.
- Resolved problems, improved operations and provided exceptional service.
Claims Pre-approval Supervisor
Metlife
Cairo
01.2009 - 01.2012
- Collaborated with team members to achieve target results.
- Managed team of employees, overseeing hiring, training and professional growth of employees.
- Led projects and analyzed data to identify opportunities for improvement.
- Reviewed and analyzed suspicious and potentially fraudulent insurance claims.
Healthcare Consultant
Weatherford IDS
Cairo
01.2007 - 01.2009
- Consulted with healthcare professionals on business decisions.
- Created and implemented organizational policies and procedures.
- Assisted with regulatory issues such as compliance.
- Created customized care plans, working with providers to assess and meet healthcare services needs.
Medical Doctor
Egypt Ministry of Health
Cairo
03.2002 - 01.2007
- Implemented therapeutic regimens involving medications and other interventions to mitigate symptoms and prevent reoccurrence.
- Interviewed patients concerning physical complaints, discussed symptoms, asked questions and suggested treatment options.
- Researched industry innovations and emerging treatments to improve care delivery.
- Management of chronic conditions inwards and out patients.
- Monitored post-operative recovery and educated patients on at-home recovery.
- ICU Specialist
- Internal medicine Specialist
Education
Bachelor of Science - Medicine
AinShams Faculty of Medicine
Cairo, Egypt 10.1994 - 12.2020
Associate of Science - Internal Medicine
Ain Shams Faculty of Medicine
Cairo, Egypt 10.2009 - 10.2010
HealthCAre Insurance Diploma - Insurance
Health Care Insurance Institute
Cairo , Egypt 01.2015 - 01.2016
Six Sigma Black Belt - Project Management
Intentional Quality Federation
01.2020 - 01.2022
Health Care Anti-Fraud Associate - Insurance Fraud
AHIP
USA 06.2022 - 11.2022
LOMA Certificate - Life And Health Insurance Operation
Life Office Management Association "LOMA"
USA 01.2022 - 11.2022
Skills
Excellent managerial techniques
Software
Qlik Sense BI
MS Office
Claims Management Systems
MS Power BI
Accomplishments
Claims Automation Projects.
Process Mapping, Customer Journey Enhancements.
Outstanding Claims Cleanliness Project management.
Closed File Review Campaigns.
Regional Business Units Audits.
TPAs Audits.
Payer Audits
Certification
Licensed Medical Doctor in Egypt
Timeline
Health Care Anti-Fraud Associate - Insurance Fraud
AHIP
06.2022 - 11.2022
LOMA Certificate - Life And Health Insurance Operation
Life Office Management Association "LOMA"
01.2022 - 11.2022
Six Sigma Black Belt - Project Management
Intentional Quality Federation
01.2020 - 01.2022
Regional Healthcare Manager
AXA-Gulf
12.2019 - Current
Licensed Medical Doctor in UAE
01-2018
Operations Support Specialist
NEXtCARE- Allianz
07.2016 - 11.2019
Precertification Manager - Critical Funds Manager
NEXtCARE- Allianz
01.2016 - 07.2017
HealthCAre Insurance Diploma - Insurance
Health Care Insurance Institute
01.2015 - 01.2016
Healthcare Insurance Precertification Manager
Alhly Medical TPA
01.2012 - 01.2016
Associate of Science - Internal Medicine
Ain Shams Faculty of Medicine
10.2009 - 10.2010
Claims Pre-approval Supervisor
Metlife
01.2009 - 01.2012
Healthcare Consultant
Weatherford IDS
01.2007 - 01.2009
Licensed Medical Doctor in Egypt
03-2003
Medical Doctor
Egypt Ministry of Health
03.2002 - 01.2007
Bachelor of Science - Medicine
AinShams Faculty of Medicine
10.1994 - 12.2020
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