Dr. Murshid Ahmed.M.B.B.S,M.B.A

• Managed team members while overseeing resubmission and reconciliation processes across Medcare group, ensuring accuracy and compliance.
• Job KPI includes Timely Resubmission, 30% recovery from Resubmitted claims, No missed Resubmission.
• Monitoring the production and quality of the team and training the team on payer's trends and rejections.
• Sharing Rejection analysis to all facilities on quarterly basis and providing frequent feedback to submission team on coding errors.
• Communicating with payers through email on any Unjustified rejections.
• Coordinated with approvals, medical records, and customer relations teams to streamline claim payment processes, enhancing communication and reducing delays.
• Maintaining Reconciliation report, by summarising the business turnover, Outstanding, Write off, with Rejection % across all payers
• Providing maximum support to finance team on closing the books within provisions.

Submission – Key Responsibilities Payer Audit & Physician Compliance

Medcare Hospital, Dubai (Apr 2022 – Till now) · Currently spearheading with Medcare Hospital - Dubai as Team Leader, for Claim submission,Resubmission,payer Audit and Doctors Training.

• Manage the end-to-end submission process, ensuring claims are accurately prepared, reviewed, and submitted within established timelines.
• Train new team members and effectively ramp them up to production, ensuring adherence to process and quality standards.
• Maintain strong knowledge of insurance guidelines, payer policies, coding requirements, and regulatory updates to support accurate claim submission.
• Analyzed monthly rejection trends, identified root causes, and collaborated with physicians, coders, and resubmission teams to implement corrective actions.
• Facilitated regular meetings with physicians to enhance clinical documentation, ensuring alignment with coding accuracy and successful claim adjudication.
• Coordinate with insurance payers to discuss rejection and denial trends, clarify payer requirements, and resolve recurring issues.
• Educate and coach team members on denial management and prevention strategies to reduce avoidable denials and improve clean-claim rates.
• Communicate and train the team on insurance-specific updates, regulatory changes, and payer policy modifications.
• Educate physicians on payer adjudication rules, documentation requirements, and claim submission guidelines.
• Develop department-specific guidelines and reference materials based on payer requirements and operational needs, and communicate them effectively to physicians and relevant teams.
• Prepare and maintain process dashboards and performance reports to monitor key metrics, identify gaps, and support management decision-making.
• Monitor submission workflows closely to ensure all claims are submitted within the defined deadlines, minimizing delays and potential revenue impact.
• Collaborate cross-functionally with coding, billing, resubmission, clinical, and payer teams to improve overall revenue-cycle performance and submission accuracy. Managed resubmission and reconciliation processes for efficient claim recovery.
• Lead and manage the Resubmission and Reconciliation team across Medcare Group, ensuring efficient claim recovery and timely resolution of rejected and unpaid claims.
• Take ownership of key process KPIs, including timely resubmission, minimum 30% recovery from resubmitted claims, and zero missed resubmission deadlines.
• Monitor the complete resubmission and reconciliation workflow to ensure claims are accurately reviewed, corrected, and resubmitted within payer-defined timelines.
• Prepare and distribute quarterly rejection analysis reports across all facilities, highlighting major rejection trends, root causes, and opportunities for improvement.
• Provide regular feedback to the submission and coding teams regarding coding errors and documentation-related rejections to prevent recurrence.
• Monitor team productivity, quality, turnaround time, and KPI performance, ensuring targets are consistently achieved.
• Train and coach team members on payer-specific rejection trends, resubmission requirements, denial prevention, and effective recovery strategies.
• Communicate directly with insurance payers via email to investigate and challenge unjustified rejections and facilitate appropriate claim resolution.
• Analyze recurring payer rejection patterns and collaborate with relevant departments to implement corrective and preventive actions.
• Conduct regular knowledge-sharing and feedback sessions to improve team performance and minimise avoidable rejections.
• Compiled and delivered monthly management presentations on key performance indicators, recovery performance, rejection trends, challenges, and action plans.
• Collaborate with submission, coding, billing, and clinical teams to improve claim quality, reduce rejection rates, and maximize revenue recovery.
• Review payer audit findings related to medical necessity, upcoding, malpractice, fraud & abuse, billing/coding errors, and lack of documentation.
• Ensure physicians follow payer billing guidelines, coding guidelines, and documentation requirements.
• Identify and correct unsupported or inappropriate claims and recurring audit findings.
• For suspended physicians, provide compliance and documentation training during the suspension period, where permitted.
• Conduct post-training audits and monitoring before reinstatement/return to billing, as applicable.
• Maintain proper documentation of findings, corrective actions, training, and follow-up audits.
  

• Manage the process of retrospective clinical and financial audits of billing practices of high risk or high utilising providers.
• Audit healthcare service providers on a regular basis and investigate suspected health insurance misuse and abuse to detect any improper payment on behalf of the plan.
• Identify incorrect coding fraudulent claims and present audit findings Review claims according to the HAAD and DHA rules and coding guidelines
• Conducted hospital visits to investigate targeted claims, adjudicate and categorise findings, present audit results, and schedule follow-up meetings with facilities' insurance managers to discuss findings and recovery amounts.
• Identifying fraud, waste & abusive trends, and active physician outreach
• Analysed provider data trends to identify patterns and insights, reviewing settled claims (Outpatient, Pharmacy, IP) based on departmental feedback, and proactively identifying scripts for high-utilisation providers and assessing treating physician behaviour.
• To implement processes to recover overcharging and support provider contractors in negotiating recoveries.
• Identify the audit sample and coordinate with the respective facility for file auditing.
• Manage routine daily medical claims administration work, along with business correspondence and addressing queries from insurance companies, clients and providers
• Coordinating workflow meeting deadlines and suggesting enhancement of services.
• Case management and evaluation of in-patient claims, including second opinions and referral to economical providers or the home country, while maintaining cost savings and TAT of 24 hours
• Manage international pre-authorisations, while coordinating with international providers for direct billing
• Validating ICD and CPT codes, as per the AAPC guidelines, for precise payments
• Represent Mednet in all external DHA- payer club meetings.
• Prospective and retrospective evaluation of medical claims, determine eligibility, and implement policies
• Conducting continuous medical education to streamline internal protocols
• Case Manager Inpatient Team - MEDNET Global Healthcare Solutions
• Coordinating workflow meeting deadlines and suggesting enhancement of services.

• Contributed 2 years of expertise as IP/OP Medical reviewer/Case Manager and reconciliation team member at Thumbay Hospital.
• Managed a team of junior reviewers, providing mentorship and guidance to enhance their skills.
• Cultivated relationships with publishers and authors to secure advanced review copies, enhancing access to valuable resources.
• Analysed and reviewed art pieces, providing clear, concise written assessments to support decision-making processes.

• Managed emergency situations effectively, providing critical care to stabilise patients swiftly.
• Prescribed and administered medication, monitoring patient response and adjusting treatment plans accordingly.
• Developed clinical protocols for sepsis, ACS, stroke, poisoning, DKA, trauma, minor injuries, pain abdomen, status epilepticus, and asthma to enhance patient care and treatment outcomes.
• Engaged with patients to understand their concerns and provide support. and family members based on emotional and communicative needs.