Dr.Mohamed Aldesouky
Dubai,United Arab Emirates
Summary
Highly accomplished and results-oriented Healthcare Insurance Leader with over 15 years of senior-level experience in claims operations strategy, management, audit, risk management, and operational excellence within the health insurance sector, specifically in healthcare. Proven expertise in developing, adjusting, and coordinating claims operations strategies and business plans for MENA Countries (UAE, Oman, Qatar, Bahrain , Saudi and Egypt), ensuring initiatives are realistic, attainable, and innovative. Demonstrated success in leading major transformational projects and complex initiatives aimed at delivering a differentiated customer experience, simplifying operations with global consistency, and strengthening foundational practices. Adept at fostering customer centricity, implementing strategic decisions, and allocating resources to sustain company-wide objectives. Skilled in overseeing large claims departments to achieve high productivity and service quality, enhancing IT systems, and ensuring robust financial controls and regulatory compliance. A strategic thinker with a strong record of maintaining operating expense ratios within budget and leveraging analytical tools for informed decision-making.
Overview
23
23
years of professional experience
6029
6029
years of post-secondary education
1
1
Certification
Work history
Regional Healthcare Claims, FWA, Clinical Governance, Audit and Risk Manager
AXA-GIG Gulf
Dubai
12.2019 - 06.2025
- Developed and coordinated claims operations strategy and initiatives across the region, focusing on operational efficiency, risk mitigation, and innovative solutions.
- Led transformational projects including system automation initiatives and the management of operational teams to ensure payment integrity, identifying malpractice and fraud, significantly contributing to cost savings and enhanced profit margins.
- Ensured customer centricity in claims operations, overseeing Clinical Governance, Providers Audit, and Fraud Waste and Abuse teams to deliver high-quality service.
- Managed Pre-Approval Guidelines and Payment Integrities at the claims level, simplifying operations and ensuring global consistency in practices.
- Assisted senior leadership in planning and executing policy decisions for operational excellence, particularly in risk management for the Health Line of Business.
- Oversaw regional audit projects, ensuring appropriate authorizations, operational and financial controls were in place to meet compliance, legal, and regulatory requirements.
- Established and utilized analytical programs and BI tools to identify trends, outliers, and areas for improvement, leading to informed management actions and data quality strategies.
- Represented the company in regulator summits and negotiations with healthcare providers, demonstrating deep understanding of the insurance environment and regulatory framework.
- Conducted regular risk assessments and CFRs, collaborating with cross-functional teams to implement mitigation strategies and reduce overall risk exposure.
- Monitored industry trends and regulatory changes, advising on necessary actions to maintain compliance and competitive advantage.
Regional Operations Support for UAE and Rest of Gulf business units/Pre-Approval Claims Manager
NEXTCARE- Allianz Partners
Dubai
01.2016 - 11.2019
- Oversaw claims department functions, managing Pre-approval, Reimbursement, and PBM teams to ensure high-quality claims adjudication as per group guidelines and medical necessity, with a strong focus on customer satisfaction.
- Maintained operating expense ratios within budget by implementing efficient claims processing and case management strategies.
- Monitored and evaluated IT systems and provider onsite doctors for case management, contributing to the enhancement of operational efficiency.
- Ensured compliance with regulatory and company standards through quality reviews, identification of discrepancies, and implementation of corrective solutions.
- Conducted internal audits across various departments, focusing on financial reporting, compliance, and operational risks, and recommended improvements.
- Prepared Business Progress Reports and Monthly/Quarterly Reports with narratives, ensuring accurate and timely management information.
- Collaborated with operations teams to enhance customer service and foster a positive work environment, involving multiple departments and organizational levels.
- Evaluated and coached staff performance, empowering individuals and managing diverse teams to drive engagement and performance.
Medical Doctor
Egypt Ministry of Health
Cairo
03.2002 - 01.2017
- Provided patient care, managed chronic conditions, and monitored post-operative recovery.
- Specialized in ICU and internal medicine.
Healthcare Insurance Precertification Manager
AlAhly Medical TPA “Part of national Bank of Egypt”
Cairo
01.2012 - 01.2016
- Managed the Pre-approval - Reimbursement Teams.
- Managed International Claims Cycles.
- Led cost-saving initiatives and operational improvements, increasing profit margins and simplifying operational flows.
- Managed dashboards and communications, improving operational efficiency by transitioning to paperless workflows and enhancing response automation.
- Developed strategies for continuous improvement and completed process documentation.
Claims Pre-approval Supervisor
Metlife
Egypt
01.2009 - 01.2012
- Supervised claims pre-approval processes, ensuring adherence to policy terms and regulatory requirements.
- Contributed to maintaining service level agreements and customer satisfaction.
Healthcare Consultant
Weatherford IDS
Cairo
01.2007 - 01.2009
- Consulted on healthcare business decisions, regulatory compliance, and customized care plans.
Education
M.D. - Medicine
AinShams University
Cairo03.2001
Diploma of Internal Medicine -
AinShams University
Cairo10.2010
Diploma of Healthcare Insurance - Healthcare Insurance
Egypt Insurance Institute
Cairo10.2014
Skills
- Senior Claims Leadership
- Strategic Planning & Execution
- Transformational Project Leadership
- Customer Centricity
- Risk Management & Compliance
- Data Analysis & Decision Making
- Stakeholder Management & Communication
- Problem Solving
- Business Intelligence Tools: Power BI-Tableau-Qlik Sense
- Claims analysis
- Time management mastery
- Underwriting principles
- Knowledge of insurance regulations
- Claim settlement procedures
- Case Management
Certification
- Harvard Business School - Certificate of Specialization in Strategy
- Insurance Underwriting- Emirates Economic Institute
- Scrum Master- Emirates Economic Institute
- Six Sigma Green Belt - International Quality Federation
- Six Sigma Black Belt
- CPMA, Certified Professional Medical Auditor - AAPC-CMS
- Certified Value-Based Care Specialist - University of Houston-USA (Focus on Development and Evolution in Healthcare Quality Measures and Outcomes)
Affiliations
- Member, Egyptian Medical Syndicate
- Member, DHA
- Member, AAPC
- Member, European Resuscitation Council
- Member, International Quality Federation
Languages
Arabic
English
Norwegian
German
References
References available upon request.
Timeline
Regional Healthcare Claims, FWA, Clinical Governance, Audit and Risk Manager
AXA-GIG Gulf
12.2019 - 06.2025
Regional Operations Support for UAE and Rest of Gulf business units/Pre-Approval Claims Manager
NEXTCARE- Allianz Partners
01.2016 - 11.2019
Healthcare Insurance Precertification Manager
AlAhly Medical TPA “Part of national Bank of Egypt”
01.2012 - 01.2016
Claims Pre-approval Supervisor
Metlife
01.2009 - 01.2012
Healthcare Consultant
Weatherford IDS
01.2007 - 01.2009
Medical Doctor
Egypt Ministry of Health
03.2002 - 01.2017
M.D. - Medicine
AinShams University
Diploma of Internal Medicine -
AinShams University
Diploma of Healthcare Insurance - Healthcare Insurance
Egypt Insurance Institute
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