didith121
About Candidate
Strong analytical, communication, and leadership
skills, along with in-depth knowledge of insurance
products, policies, laws, and best practices
18 years of solid experience in the UAE and
international medical insurance claims processing
Proficient in using claims processing software and
systems, MS Office
Trustworthy, self-driven, dedicated, work extensively
Undergone effective leadership trainings
Well-versed in official coding guidelines including
ICD-10-CM, CPT, HCPCS, CDT, and DDC for
compliance and accurate recording practices
Location
Education
Occupational therapy (OT) is a type of healthcare profession focused on helping people participate in the activities (occupations) they want and need to do in daily life, despite physical, mental, or cognitive challenges. The “occupation” in OT doesn’t just mean a job—it means any meaningful activity, such as self-care, work, school, play, or leisure.
Work & Experience
Manage daily operation of the water station Maintain equipment, inventories, supplies and facilities Manage finances, budget and monitor cash flow Comply with regulations, ensure water quality, maintain certificates, permits and licenses
Manage and oversee the entire medical claims process, ensuring efficient processing, compliance with regulations, and timely payments, while also managing costs and preventing fraud Implement and control claim costs, enforce agreed tariffs, conduct utilization reviews, audits of internal and external system process Conduct quality assurance reviews and ensure compliance with the Dubai Health Authority ( DHA) and Health Authority of Abu Dhabi (HAAD), international and offshore team Collaborate and resolve issues with the Local and International Providers, Medical Board, Direct Billing, Reimbursement, Network, Customer Service, Auditing, Fraud, Waste and Abuse departments to achieve company objectives and ensure compliance is aligned with the medical claims procedure protocol Closely monitor and track claims payment turnaround times to ensure timely payments to beneficiaries Ensure that performance-based appraisal of departmental staff is in line with their set KPIs and departmental targets. Prepare regular claims and operations reports to management, intermediaries, and clients and advise the underwriting team on relevant claims findings for medical risk review
Lead and manage the medical claims team, ensuring accurate and timely processing of all claims. Develop and enforce policies, procedures, and compliance standards for claims operations. Monitor claims quality, identify discrepancies, and implement process improvements. Handle escalations from clients, providers, and internal teams efficiently. Analyze claims data to track trends, costs, and performance metrics for management reporting. Mentor and train staff, fostering a culture of accountability and continuous improvement.
Review and verify medical claims for accuracy and completeness according to insurance policies. Process claims for payment, adjustment, or denial based on coverage and documentation. Maintain accurate records and enter claim data into the system. Communicate with healthcare providers, patients, and internal teams to resolve discrepancies. Ensure compliance with regulatory guidelines and internal procedures. Identify potential fraudulent claims and escalate when necessary.
Enter claims data into computer systems, ensuring accuracy and attention to details Identify and resolve claims, applying rules and guidelines to determine payment Maintain accurate and detailed records of claims processing and communication
