Medical Customer Service

Sujisha Anoop

Al Ittihad Road, Dubai, UAE

Mob : 009**-**-*******

Email : ***********@*****.***

Substantial experience and outstanding skills in Healthcare Insurance, Process Management with 4 plus years of experience which enable to work in a fast paced environment with the ability to think quickly and excellent interpersonal skills and solid decision making, hard-working and result driven attitude.

CORE COMPETENCIES

Profound knowledge of Health care Insurance, Medical Coding, Process Management.

Able to work in a pressurized environment with continuous deadline and capable of making quick decisions in time constraint situations.

Energetic personality consistently praised for my passion for work and upbeat, positive attitude.

Proficiency in Microsoft Office programs (Word, Excel, PowerPoint and Outlook).

PROFESSIONAL EXPERIENCE

Medical Claims Supervisor

GMC healthcare LLC

September 2017- Present.

Claim submission/ Resubmission/ Reconciliation/ Pre-approvals

Provide daily support to claim staff on claim managing and filing activities.

Ensure that claim team follows state regulations and standard operating procedures.

Assist claim personnel in coverage investigation, liability analysis and settlement negotiation.

Develop best practices to optimize claim processing quality.

Evaluate professional skills of claim staffs and provide appropriate claim assignments to them.

Establish expense reserves for claim investigations.

Resolve coverage issues and approve coverage denials.

Perform claim negotiation and confirm settlement amount.

Document claim assessment and filing activities accurately.

Oversee medical, insurance and legal aspects of assigned claims.

Interact with Claimant, Attorneys, Polices and other public to achieve claim settlement.

Assist in hiring and training new candidates in their job responsibilities.

Monitor individual performance and ensure it meets expected quality and performance objectives.

Develop professional development plans for employees to improve performance efficiency.

Assist in employee performance evaluation, promotion, retention and termination activities.

Network Related Job responsibilities:

Responsible for establishing and maintaining processes and systems to provide routine services to members including contract management and credentialing.

Recruits, hires, trains, and measures performance of staff to provide effective and operations within budget.

Receives information from outside parties for update of provider-related information in computer system(s).

Reviews/analyses data by applying job knowledge to ensure appropriate information has been provided.

Maintains department quality standards for provider demographic data with affiliation and procedures for new insurance companies empanelment

Ensures accurate entries of information into health plan systems.

Medical Claims Administrator (client facing admin)

Marsh & Mclennan.co

(March 2016– August 2017)

Verifying all claim documents received for completion of required claim documentation.

Submitting all complete claim documents to the assigned insurer for processing in line with the policy.

Sending follow-ups to the insurer for claims still under process but beyond agreed TAT (Turn-Around-Time) through email or phone.

Attending queries of the client promptly related to claims through e-mails and telephone calls.

Preparing TAT reports to the clients as per their request.

Ensuring that all denied and suspended claims are in accordance with the policy terms & conditions. Otherwise, readdress the same to the insurer for reprocessing.

Dispatching settlement cheques and advices from the insurer to the clients.

Performing duties assigned by the Claims Manager in a day to day basis without delay.

Medical claim officer (Medical Benefits)

Emirates Airline

(March 2015 – March 2016)

Administration and formulation of database of eligible employees and dependants.

Maintain filing system of all claims, invoices and other related documents in order to be made for retrieval.

Process all medical claims received from employees and eligible dependants, which involve verification on policy rules, data input preparation of files for payment in accordance with set procedures and deadlines

Process all invoices received from external medical service providers. This involves verification on policy rules, review of costs, accounting rules, accurate calculation of discount and processing payments in accordance with set procedures, contracts and deadlines.

Timely audit and maintenance of accounts and hospital balances in accordance with the company policies and procedures of auditing.

Identify, design and review systems processes enhancements and modifications and possible areas of cost management for Medical Benefits Administration.

Responsible for all aspects of customer service for both internal and external customers. And ensuring everyone is given a clear, professional and accurate response. Guide and advice staff on proper claims process and details on medical policy

Medical Claims Officer

Dubai Insurance Company.

(August 2014 – January2015)

Monitor daily target of the reimbursement team and maintain TAT for Reimbursement claims processing

Send electronic bordereau of the E- claims to the payers in order to inform them of approved claims and settlement amounts

Prepare weekly and monthly processing reports for internal and external usage of information

Answer provider/ insured members / PICs queries relating to claims processing, coverage limit inquires as and when required

Train newly hired processors / PICs/Brokers/Insured Groups in reimbursement claims processing

Review and audit the reimbursement claims processed in line with auditing guidelines and introduce innovative ways to minimize errors and enhance quality standards Analyze medical trends / utilization rates and detect any fraud and abuse cases Entering claims data into system

Resolve problems resulting from claim settlement

Follow adjudication policies and procedures to make sure proper payment of claims

. Provide timely customer service to members, providers, billing departments and other insurance companies on the subject of claims

Insurance officer/Medical coder

Symbiosis Medical Centre, Dubai (January2014 – July 2014)

Coordinating, liaising and networking between insurance companies regarding eligibility, payments, approvals, reconciliation and other requirements

Medical claims processing

Entering data and coding the activities and diagnosis as per CPT coding and then entering the complete information through e-claim link to authorized providers and payers

Responsible for filing and tracking insurance claims and informing patients of their claims status Process insurance and disability claims in a timely manner

Prepares insurance forms and associated correspondences Entertains patients’ queries regarding unpaid balances

Liaise with patients regarding their eligibility and entitlements

Maintains strict confidentiality related to medical records and other data skill

Education

Pursuing CII (UK)

Masters in Nursing (Neurology)

Medical coding & Billing

Bachelor of Nursing

DELFA1(French)

IELTS

Personal Details

Spouse Name

: Anoop Ashokan

Date of Birth

:

14th March 1985

Languages

:

English, French, Malayalam.

Reference

Available upon request.

Contact this candidate