Hipai Andrew Elisa
Al Ain
Summary
Highly trained professional with a background in verifying insurance benefits and creating appropriate patient documentation. An established Insurance Verification Specialist known for handling various office tasks with undeniable ease. Organized and dependable candidate successful at managing multiple priorities with a positive attitude. Willingness to take on added responsibilities to meet team goals, to seek and maintain a full-time position that offers professional challenges utilizing interpersonal skills, excellent time management, and problem-solving skills.
Overview
8
8
years of professional experience
Work History
Medical Insurance officer
UAP Insurance”IP Obs/Gynea
08.2021 - 12.2022
- Evaluate and adjudicate outpatient claims and provider prior approval as per the medical necessity and policy terms and conditions
- Handle the calls and queries from the provider relating to medical cases and policy details
- Manage queries from the providers and insured members relating to claim processing, policy details, adjudication, technical details, etc
- Coordinate with different departments to ensure the quality and accuracy of the claim processed.
- Verify requests with insurance policies, check medical information such as disease or symptoms and diagnostic Descriptions & recommended procedures for treatment, and determine if the requested procedure is justified
- Approve medical authorization requests and share with supervisor for final approval
- Communicate the approved medical authorization request to the service provider and ensure proper records
- Handle all calls from the health care providers or follow-up calls on medical authorization
- Examine medical treatment records, police reports, and medical bills to gauge the overall extent of liability
- Approve or reject documentation to determine benefit due and start the denial of payment process's resolve medical claims as well as investigate suspected misuse and abuse (fraud) cases related to client case.
- Ensure compliance with health care regulations and safety standards
- Review clinical data matching it against specified medical terms and diagnosis/procedure codes and follow established procedures for authorizing approvals request
- Issuing day care and inpatient cases re-reimbursement approval in line with medical policy coverage
- Collect and document accurate and reliable data on illnesses, and accident absenteeism to provide statistics on illness and the medical risk taken by all staff
- Examine medical treatment records, police reports, and medical bills to gauge the overall extent of liability
- Ensure all Claims information remains confidential
- Engage in continuing education training opportunities when possible.
- Complied with established internal controls and policies.
- Established internal audit procedures to validate and improve the accuracy of financial reporting.
- Developed strategic plans for day-to-day financial operations.
Staff Health Officer
International Committee Of Red Cross
06.2017 - 07.2021
- Inspecting and updating patients' charts
- Ensuring the highest standard of patient care and maintained
- Diagnosing common illnesses such as colds, flu, diabetes, and other diseases
- Referring patients to specialists for further testing and treatment, if needed
- Submitting claims on behalf of patients who have health insurance
- Successfully negotiated client contract renewals to create increased revenue.
- Implemented successful healthcare program through professionalism, quality of care, medical teaching, and patient satisfaction.
- Established internal audit procedures to validate and improve the accuracy of financial reporting.
- Evaluated and negotiated contracts to procure favorable financial terms.
- Developed strategic plans for day-to-day financial operations.
- Established and checked coding procedures, monitored reports, and updated internal files.
- Prepared cash flow projections, cost analysis, and monthly, quarterly, and annual reports.
- Recruited, hired, and trained all staff, providing direct supervision, ongoing staff development, and continuing education to employees
- Evaluated medical claims for accuracy and completeness and researched missing data
- Resubmitted claims after editing or denial to achieve financial targets and reduce outstanding debt
- Prepared insurance claim forms or related documents and reviewed for completeness
- Verified client information by analyzing existing evidence on file
- Identified and resolved discrepancies between patient information and claims data
- Paid or denied medical claims based upon established claims processing criteria
Medical Officer
Gudele Medical and Surgical Home, GMSH
09.2016 - 07.2021
- Directed and coordinated patient care activities of nursing and support staff.
- Completed patient referrals to other medical specialists.
- Improved patient outcomes and delivery of care through improved clinical quality processes.
- Assisted senior physicians and surgeons during assessments, examinations and surgical interventions.
- Interpreted diagnostic test results for deviations from normal.
- Confirmed consistent and accurate medical recordkeeping practices.
- Discussed medical histories with patients in effort to provide most effective medical advice.
- Liaised with other healthcare professionals to develop comprehensive patient care plans and provide highest quality of care.
- Conducted routine facility inspections, identifying areas needing improvement and eliminating hazards posed to staff and residents for continued compliance with associated regulations.
- Implemented successful healthcare program through professionalism, quality of care, medical teaching and patient satisfaction.
- Communicated with patients, ensuring that medical information was kept private.
- Established and maintained effective communication with staff, physicians and community organizations to promote high quality patient care.
House Officer
Omdurman Military Hospital
11.2014 - 11.2015
- Wrote detailed narrative reports for use in investigations.
- Attended personnel meetings and training sessions to improve skills and learn new policies and procedures.
- Prepared and submitted detailed reports regarding assignments and ongoing investigations.
- Supervised, directed and evaluated assigned staff members and newly hired officers.
- Completed daily rounds to check on patients and identify any reasons for concern.
- Reviewed clinical cases to gain additional understanding of disease etiology and progression.
- Responded to medical emergencies to help stabilize and treat patients.
- Detected changes in health status with careful examinations and close patient monitoring.
- Worked with multi-disciplinary team to develop patient treatment plans for patients.
- Presented information on health education topics to patients and families.
- Participated in lab and diagnostics testing to help diagnose and treat patient illnesses.
- Provided patient care under direct physician supervision.
- Built strong foundation in medical practice by contributing to different areas of patient care and administrative practice.
- Made the appropriate referrals and booked patients for elective surgeries, minor surgeries, and debridement.
Education
MBBS - Medicine
El Razi University of Medical Sciences And Technology
Khartoum - Sudan07.2014
Skills
- Skills & Experience
- Skilled in completing daily medical consultations, follow-ups, and critical care management and in guiding others on policies, strategies, and health program guidelines and protocols
- Technologically adept with advanced skills in Microsoft software suites Strong reporting, guidance, and counseling capabilities A recognized team, program, project, and operations leader with outstanding communication skills
- Proficient knowledge of medical terminology, ICD-10, CPT, and HCPCS coding (APC & DRG)
- Prompt prior authorization response to approvals and submission of information accurately ensure
- Eligibility
- Examine Claims records and forms
- Fast problem-solving, time management, and team collaboration
- Knowledge of medical insurance terminology
- Proficiency in medical management systems
- Analytical and Critical Thinking
- Strategic planning, scheduling & Staff Management
Languages
English
Advanced (C1)
Arabic
Bilingual or Proficient (C2)
Timeline
Medical Insurance officer
UAP Insurance”IP Obs/Gynea
08.2021 - 12.2022
Staff Health Officer
International Committee Of Red Cross
06.2017 - 07.2021
Medical Officer
Gudele Medical and Surgical Home, GMSH
09.2016 - 07.2021
House Officer
Omdurman Military Hospital
11.2014 - 11.2015
MBBS - Medicine
El Razi University of Medical Sciences And Technology
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