DR.MOHAMED SAMEER Buhari BHMS, CPC

• Managed cases involving various case management triggers, including:
  →DRG severity reviews and potential upcoding incidents
  →Repeated admissions or procedures, High-cost cases
  →Suspected fraud and abuse
  →Cases requiring the rule-out of iatrogenic causes
  →Unresolved cases at the prior approvals level
  →Cases requiring a Second Medical Opinion (SMO) for further evaluation and decision-making
• Conducted regular field visits to hospitals for unresolved or conflicted cases, cases suspected of iatrogenic causes or abuse, and cases with incomplete medical justification.
• Acted as the spokesperson for hospitals in addressing pending and conflicted cases, ensuring appropriate communication, resolution, and coordination through monthly meetings.
• Conducted file audits for individual and group policies.
• Handled high-premium policies with great care and attention, maintaining a complaint-free record.

• Case management for Complex and Disputed cases by analyzing the root cause of admission, Patient's progress, Treatment plan, Ruling out I atrogenic causes , HAI in Inpatient cases .
• Evaluating DRG , High cost Add-on Surgeries, Drugs and Consumables , LTC, Outliers according to DHA and HAAD Adjudication rules.
• Careful application of Policy benefits according to TOB and Calculating Policy Sublimit and Annual Limit subject to exhaustion.
• Secured SMO consultation for challenging and ambiguous surgical cases, ensuring positive patient outcomes.

Roles & Responsibilities:

• Evaluate Medical Approvals for outpatient and inpatient services based on Treatment Plans, Medical Justification, and Policy Terms and Conditions.
• Assess the severity of IP-DRG, CPT codes , Add On Payments, Outliers according to Coding Guidelines and Treatment Management.
• Adhere to Turnaround Time ( TAT ) for approvals and denials.
• Strictly follow the Authorization Limit given by payers and seek approval from payers beyond the limit.
• Provide Manual Approvals for Non-network and other Northern Emirates providers.

Additional roles:

• In-depth Case Analysis and Strong negotiation with the providers for Highly Complex and Long term care cases.
• Maintain regular communication with payers to submit Claims Utilization reports, COVID reports, PSP reports, etc.
• Invest Strong focus and efforts for Smooth Renewal of Policies with Clients.
• Monitoring providers and taking actions for Abuse ,Overuse and prevention of unjustified medical services.

• Worked as COVID medical officer for 18 months.

• Worked as Duty Medical officer for 1 year.