Medical Approval Officer, Rejections resubmission
NMC Royal Women's Hospital, Abu Dhabi
01.2021 - Current
Hi, I’m
Medical Approval, Claims processing Officer
Abu Dhabi
Summary
High performing professional medical authorization and claims processing officer with 15+ years’ experience in medical authorization (pre-approvals), medical claims processing, examiner, coder resubmission in the reveneue cycle team. Provider relations in the medical insurance industry having solid knowledge of medical insurance management and procedures. Served medical insurance customers by determining insurance coverage, examining and resolving medical claims, documenting actions, maintaining quality customer services and ensuring legal compliance through significant knowledge of medical and health insurance concepts, industry terminologies and accurate coding. I could be a great asset. Also worked I pharmacy and well versed with pharmacy benefit management and approvals and rejection for pharmacy related to diagnosis. Served also as a health insurance support agent in daman. Flexible to all shifts . Hard working.
Additional nursing and clinical experience of 14+ years. Having a strong supervisory and analytical ability, I am seeking a steady position as an Insurance Officer prepared to work long term with the right organization. CORE COMPETENCIES Claims and Authorization Processing and customer service along with, a wide knowledge of medical field including pharmacy and insurance.
Work history
Insurance Company, Abu DhabiAbu Dhabi
Medical Authorization Officer, Claims resubmission
01.2020 - Current
Job overview
- Implement insurance policies and procedures and give written approvals. 80 to 100 approvals and rejections per day.
- Resubmission of denied claims as per work allocation and denial analysis with timely feedback. Following up of approval, rejections, explaining rejections and policies and answering queries regarding SOBS and rejections.
- Review rejections from payers and assign appropriate codes based on response from physicians for queries raised after rejection .
- Following up complicated cases with the doctors and concerned of the Authorization dept
- Escalating urgent and emergency cases, Delayed requests more than TAT
- Answering regarding coverage of medicines and related diagnosis, coverage as per policy, queries as per benefits and copay
- Clarifying rejection codes
- Checking for the errors of authorization and following up
- Addressing claims regarding PRD
- Claims and policy renewals
- Develop the medical knowledge in medical insurance to the overall team
- Coordinating with underwriting department, customer care center, claims department and network
- Scrutinize, analyze and process the request note (claim form) provided by the hospital and take the suitable justifiable decision on the claim request
- Coordinating with treating Doctor for settlement of claim
- Cost control of the med claim
- Provide training to new joiners in the authorization department
- Taking full responsibility during night shifts of calls approvals and pending issues.
Ministry Of Health Oman
STAFF NURSE And CLINICAL INSTRUCTOR
01.1989 - 01.1992
Job overview
- Muscat, Muscat Governorate, Oman
- Medical surgical, Maternity, Orthopedic, ICU and ICCU
- Also taught nurses, giving lectures and clinical instructor.
Bombay HospitalMumbai
Nursing Tutor
Job overview
- Worked in the Medical, surgical male and female wards, pediatrics, accident and emergency, maternity and OPD providing nursing care to patients
- Demonstrated procedures to nurses in the wards and gave lectures on Medical nursing and procedures
- Taught subjects like Anatomy and Physiology and Medical surgical procedures.
NMC Royal Women's Hospital, Abu DhabiAbu Dhabi
Medical Approval Officer, Rejections resubmission
01.2021 - Current
Job overview
- High-performing professional medical authorization officer with 15+ years of experience in medical authorization (pre-approvals), medical claims processing, coding, automation and provider relations in the medical insurance industry. Working for RCM team.
- Review rejections from payers and assign appropriate codes based on response from physicians for queries raised after rejection.
- Monitoring of denial trends and reporting it to the Manager and ensuring feedback is given to the concerned unit.
- Served medical insurance customers by determining insurance coverage, examining and resolving medical claims, documenting actions, maintaining quality customer services and ensuring legal compliance through significant knowledge of medical and health insurance concepts, industry terminologies and accurate coding
- Additional nursing and clinical experience of 10+ years
- I am looking for a position where I can use my varied experience in the medical and health insurance field
- Applying for approvals for patients as per the policy following approval guidelines
- Coordinating with various Insurance companies for approvals
- Assisting medical staff on coverage and policy benefits
- Arranging for related reports from doctors
- Replying to approval queries and rejections
- Familiar with portals of Daman, Next care, NAS, Neuron, MetLife
- Oman insurance, AXA and mednet etc
- Coordinating with insurance companies on updates and policies
- Very familiar with ICD codes, DRG, coding rules,general exclusions, policies and benefits
- Handling patient grievances related to rejections
- Attending calls and follow ups from doctors
- Following up to get approvals within TAT
- Using right strategy and methods and as per DOH and HAAD guidelines.
Daman National Health Insurance Company
Medical Authorization Officer
01.2012 - 10.2020
Abu DhabiAbu Dhabi
Clinical instructor
08.2010 - 12.2011
Job overview
- Following up of approval, rejections, explaining rejections and policies and answering queries regarding SOBS and rejections related to coding guidelines and adjudication rules
- Addressing
- PRD related queries
- Issuing approvals related to pharmacy and out-patient
- Clarifying guidelines and rejection codes along with pre-approval requirements with providers related to benefits and exclusions of the policies
- Well versed in Med next, PBM, ICD10 coding, CPT coding, E-authorization tools
- Provider Network Management
- Case Management, Daman,National Health Insurance Company
- Abu Dhabi,Abu Dhabi, United Arab Emirates
- Taking valid decisions
- Escalating issues to the related department
- Updating on circulars and change
- Training providers on policies and procedures for approval, also guiding on use of the daman portal
- Also dealing with home care rejections
- Also dealing with homecare approvals and rejections
- Diabetes, Asthma and Maternity Management
- Holistic health coaching and obesity management for diabetics, checking on diabetic cases in disease-management and how to live with diabetes, and on diet management, physical activity, and obesity management
- How to self-manage
- Following up with their treatment and insurance coverage
- Managing chronic diabetics
- Holistic health coaching and periodic follow up for members from conception until delivery
- Gave presentations and furnished articles on health topics like smoking and diabetes
- Trained with the lily Map
- Screening members
- Detect diabetics in time and prevent further complications
- Also contributed to related marketing events conducted by Daman
- Management of maternity cases from first trimester till delivery
- Educating them on monthly, - Taught nursing Procedures to student nurses.
Daman National Health Insurance Company, Abu DhabiAbu Dhabi
Insurance Agent
09.2009 - 09.2010
Abu Dhabi National Health Insurance Company, Abu DhabiAbu Dhabi
Senior Claims Examiner
05.2006 - 05.2010
Job overview
- Handles calls and issues of the customers in order to provide the appropriate assistance and guidance in resolving issues related to the business
- Claims processing and issuing approvals
- Network management
- Checking on prices in the market and settling the discounts and contracts with the supervisor and the manager
- Dealing with providers complaints, payments, claims not received and not paid
- Reviewing claims and settling them
- Checking international claims that need to reimburse and checking for the shortcomings and billing
- Discussing high cost claims with the managers
- Develop the medical knowledge in medical insurance to the overall team
- Back up of authorization officer/coordinators in case of any performance deficit
- Handles calls and issues of the customers to provide the appropriate assistance and guidance in resolving issues related to the business.
AL Khazna Insurance, Abu DhabiAbu Dhabi
Medical Claims Processor
01.2004 - 07.2004
Job overview
- Claims processing and issuing approvals
- Network management
- Issuing letters for agreement or contract to the respective providers.
NAS Administrative Services, Abu DhabiAbu Dhabi
Medical Claims Processor And Authorization
01.2002 - 01.2004
Job overview
- Processing claims as per policies and procedures
- Back up of authorization officer/coordinators in case of any performance deficit
- To organize weekly team meetings, preparing the agenda of the team meeting, giving presentations of medical topics related to medical insurance.
KHIMJI PHARMACY
Medical Representative
01.1996 - 01.2000
Job overview
- Coordinating with underwriting department, customer care center, claims department and network department
- Handles calls and issues of the customers to provide the appropriate assistance and guidance in resolving issues related to approvals
- Coordinating with treating Doctor for settlement of claim
- Cost control of the med claim
- Provide training to new joiners in the authorization department
- Marketing surgical solutions, disposables and other wellness products to pharmaceuticals and healthcare decision makers.Accident And Emergency Nurse, Royal Oman Police Hospital
- Abu Dhabi, Abu Dhabi, United Arab Emirates
- OPD and Emergency nursing.
Education
Trained in medical coding, ICD
University overview
10, CPT and HCPCS.
Communication skills
Bachelors Degree from Nursing
Health
Women's University
Bachelor's
12.1996
UAE from Decision making
01.1995
Certificate in Health care quality management (CPHQ). (Underwent training)
Certificate in effective communication and customer service in health care.
01.1989
insurance concepts
Medical coding Certificate
Certificate in Lily Map Training for Diabetics.
Certificate CME in Obesity and Morbid Obesity, Integration and Standardization
11.1986
Skills
Coding ICD and DRG
- Insurance Authorizations, exclusions and benefits
- Resubmission of rejections with justification
- Claims Auditing
- Claims Processing
- Customer service
- Prioritization
- Leadership
- Health Insurance
- Teaching
- Problem Solving
- Stress Management
- Communication
- Presentation Coaching
- Microsoft Word
- Microsoft Excel
- Microsoft Office
Languages
English
Fluent
Arabic
Upper intermediate
Hindi
Fluent
Marathi
Fluent
Punjabi
Fluent
Malayalam
Intermediate
Timeline
Medical Authorization Officer, Claims resubmission
Insurance Company, Abu Dhabi
01.2020 - Current
Medical Authorization Officer
Daman National Health Insurance Company
01.2012 - 10.2020
Clinical instructor
Abu Dhabi
08.2010 - 12.2011
Insurance Agent
Daman National Health Insurance Company, Abu Dhabi
09.2009 - 09.2010
Senior Claims Examiner
Abu Dhabi National Health Insurance Company, Abu Dhabi
05.2006 - 05.2010
Medical Claims Processor
AL Khazna Insurance, Abu Dhabi
01.2004 - 07.2004
Medical Claims Processor And Authorization
NAS Administrative Services, Abu Dhabi
01.2002 - 01.2004
Medical Representative
KHIMJI PHARMACY
01.1996 - 01.2000
STAFF NURSE And CLINICAL INSTRUCTOR
Ministry Of Health Oman
01.1989 - 01.1992
Nursing Tutor
Bombay Hospital
Trained in medical coding, ICD
Bachelors Degree from Nursing
Health
Women's University
Bachelor's
UAE from Decision making
Certificate in Health care quality management (CPHQ). (Underwent training)
Certificate in effective communication and customer service in health care.
insurance concepts
Medical coding Certificate
Certificate in Lily Map Training for Diabetics.
Certificate CME in Obesity and Morbid Obesity, Integration and Standardization
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