Ghazal Amer
AbuDhabi,UAE
Summary
Highly skilled healthcare professional with more than seven years of experience in Pharmacy Benefit Management, Drug Utilization Review and Automation process Optimization. Expert in implementing government initiatives to manage Drug cost block through system enhancements and drug utilization reviews. Adept at analyzing healthcare economics, optimizing workflows and driving strategies for cost efficiency in health insurance and healthcare delivery systems. Proven ability to lead cross-functional teams and deliver innovative solutions for complex challenges in pharmaceutical and healthcare operations.
Overview
9
9
years of professional experience
6
6
years of post-secondary education
Work History
PBM Specialist- Automation Process Optimization
National Health Insurance Company- Daman
Abu Dhabi, UAE
10.2018 - 01.2025
- Monitor PBM system performance and availability as well as daily inflow /outflow to ensure compliance with relevant SLAs and KPIs related to TAT and high Automation Rate
- Engage with relevant IT teams and other business units to resolve PBM technical issues
- Ensure up-to-date knowledge of technical process flow of PBM systems, regulatory requirements, internal Policies and Procedures, coverage guidelines and Schedule of Benefits
- Prepare and execute testing activities on the PBM system to validate expected system behavior and implementation of new system enhancements
- Drive further development of automation processes, where sensible, to contribute to OPEX reductions as well as enhanced customer experience
- Contribute to the rule engines content enrichment and updates to support cost savings and operational efficiencies
- Oversee the quality review processes throughout the Medical Operations division
- Define Daman's competitive edge by finding the right balance between the provision of excellent member services and the necessity of keeping spending reasonable, ensuring profitability
- Act as an inhouse business consultant to Daman, its business partners and regulatory bodies on health insurance transformation and expansion projects
- Conduct Data mining and analytics activities related to pharmaceutical dispensing aiming to identify data driven actionable items and relevant cost optimization initiatives
- Conduct audit activities related to PBM submissions to identify and prevent abusive patterns at provider level and member level
- Report suspected cases of fraud and/or abuse of the healthcare providers via the relevant internal channels
- Conduct audit activities related to internal systems / rule engines decision outputs to enhance decision making and prevent financial loses
- Record and track saving realizations of the implemented projects and initiatives
- Coordinate with relevant teams to enhance and update the decision content on pharmaceutical coverage to enable adequate controls on PBM transactions and achieve patient safety and justified expenditure on pharmaceutical cost block
- Support medical providers with PBM related queries and technical advice
- Conduct Pharmacy / PBM related trainings and awareness sessions
- Manage Member appeals received via various channels, including happiness center, sales, brokers and call center
Support Chief Processing Officer office
National Health Insurance Daman
04.2018 - 10.2018
- Act as a key liaison between CPO office and operational teams facilitating clear communication and issue escalation
- Provide weekly updates on Authorization & Case Management department performance and operational metrics
- Handel VIP complaints ensuring prompt resolution and maintaining high levels of customer satisfaction
- Collaborate with cross-functional teams including Medical Audit and Claims department to address complex cases and ensure seamless workflows
Medical Authorization Officer
National Health Insurance Daman
06.2017 - 04.2018
- Review and process prior authorization requests of outpatient medical services in compliance with policy guidelines
- Ensure all required documentation is complete and accurate to facilitate timely approvals or denials
- Conduct monthly audit for Pre-authorized Outpatient Services and discuss findings with the line manager and relevant stakeholders
Pharmacy Professional License
Al Daman Pharmacy
Abu Dhabi
01.2017 - 12.2017
International services Officer
National Health Insurance Daman
03.2017 - 06.2017
- Perform International Claims adjudication and reconciliation processes
Patient consultant and educator (Internship program)
Abbott
UAE
06.2016 - 10.2016
Education
B.Sc. - Pharmacy
University of Sharjah
Sharjah 09.2011 - 09.2016
MSc - Healthcare Management
Swiss Business School
UAE 11.2019 - 02.2021
Skills
- Pharmacy Benefit Management (PBM)
- System Enhancement and implementation
- Process Automation and Workflow Optimization
- Regulatory Compliance and Government Health system Initiatives
- Drug Utilization Review and Cost Optimization
- Data analysis and Decision Support
- Stakeholder Engagement and Cross Functional Leadership
- Microsoft Office word
- Excel
- Power Point
- SOAP UI
- SAS
Accomplishments
- Lead/work on projects and initiatives to implement PBM system enhancements
- Lead/work on projects and initiatives to implement cost optimization controls for Drugs cost block
- Lead/work on projects and initiatives aimed to enhance customer experience and satisfaction (Daman system Status Dashboard, DS360 Request Management)
- Restructuring PBM quality check by introducing new audit processes
- Full PBM roll-out to all insurance plans across UAE healthcare providers
- Reformation of medications early refill and replacement process
- Analyzed and interpreted Drug Cost block data to evaluate market utilization behavior and identify trends, successfully transforming regulator driven directives into strategic initiatives with minimum 10% savings from the overall expenditure
- Introduction of High-cost and Biologics Automation of refills process
- Introduction of Daman Closed Drug Formulary & Referenced Price Drug Formulary
- Achieved and maintained 99% PBM system availability between 2019 & 2024 by recommending effective approaches/solutions to improve the system performance
- Enrich Daman Medical and Business Rule Engines by introducing new rules (Clinician specialty rules, Service-encounter type rules, Eligibility check rules, Maximum allowable quantity rule, Duplicate Therapy rule & History checks)
- Training Providers prior PBM roll-out and System updates to maintain departmental Service Level Agreement
- PBM awareness sessions to Internal stakeholders to optimize management of customers complaints
Training Courses
- Project Management- Fundamentals
- Project Management Essentials
- Fraud Identification & Management
- Lean Six Sigma for Insurance
- Creative Problem Solving
- Data Consolidation & Analysis Using EXCEL
- Medical Coding: ICD-10-CM & CPT
- Data and Health Indicators in Public Health Practice
- Leading effectively
- Business Process Re-engineering
Languages
English
Fluent
French
Upper intermediate
References
References available upon request.
Timeline
MSc - Healthcare Management
Swiss Business School
11.2019 - 02.2021
PBM Specialist- Automation Process Optimization
National Health Insurance Company- Daman
10.2018 - 01.2025
Support Chief Processing Officer office
National Health Insurance Daman
04.2018 - 10.2018
Medical Authorization Officer
National Health Insurance Daman
06.2017 - 04.2018
International services Officer
National Health Insurance Daman
03.2017 - 06.2017
Pharmacy Professional License
Al Daman Pharmacy
01.2017 - 12.2017
Patient consultant and educator (Internship program)
Abbott
06.2016 - 10.2016
B.Sc. - Pharmacy
University of Sharjah
09.2011 - 09.2016
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