I’m a registered nurse with 10 years medical insurance experience in the United Arab Emirates and 3 years hospital experience in the ----------- such time I am already exposed and well acquainted with various insurance works and administrative processes such as below:
? Authorize approval based upon member coverage & medical justification.
? Assist queries from providers and payers via phone calls or emails.
? Maintains files for authorizations and other reports.
? Assess and Process claims in line with the policy coverage and medical necessity.
? Fully versed with medical insurance policies for various groups / beneficiaries.
? Assist in training colleagues and sharing knowledge.
? Assess eligibility within the UAE (HAAD and DHA) guidelines as well as policy boundaries.
? Monitors and maintains the claims processing and adjudicating cycle in the operational software system as per the defined terms and policy of the organization.
? Ensures the proper communication and implementation of new formats, training and processing rules.
? Enters and processes/ adjudicate claims in an operational software system as per the terms and policy of the organization.
? Ensures Adherence to the predefined TATs for claims and pre-approvals.
? Achieves required processing targets assigned by the team leader on a daily, weekly and monthly basis.
? Manages claim life cycle, denial handling and resubmissions.
? Verifies and prepares the claims, insurance recoveries and reconciliation.
? Maintains the existing insurance and corporate network and new network empanelment.
? Implements Insurance procedures and policy.
? Details and oversight on Accounts Receivable from Insurance and clients and timely reconciliation.
? Coordinates / follow-up with insurance companies for remittance collection.
? Coordinates with the coding team for E-Claim xml submission/re submission.
? CPT level agreements and rate negotiation with insurance companies.
? Ensures compliance with HAAD laws and industry regulations.
? Conducts training to staff for correct usage of claim forms and approval letters.
? Verifies card validities and schedule of benefits of a specific plan and policy.
? Explaining coverage of medical benefits to patients when required
