Claims Executive

• Jul 2021 - Present

Insurance Coordinator

• Jul 2020 - Jan 2021

Medical Claims Adjudicator

• Jul 2019 - Jun 2020

• Adjudicate and process all e-claims & manual claims (Outpatient, Inpatient, Resubmission, & Reimbursement) effectively according to the policy terms and conditions• Review and validate group medical claims, assuring the accurate input of name, date, diagnosis, laboratory tests, procedures, treatments and pre authorization• Review member eligibly when necessary. • Assess medical necessity, frequency, and unbundling• Equate claim amounts with the agreed tariff when necessary• Apply DOH, DHA, MOH and generally accepted processing guidelines • Process claims on time meeting productivity and quality targets • Provide support as and when needed to medical claims department in accessing claims • Provide support to Understanding & Network team when necessary• Liaising with any internal or external people to discuss medical conditions to continually strive to improve and develop medical knowledge• Knowledge about CPT codes, DRG, ICD-10 and AIMS system Show less

Pre Authorization officer

• Dec 2015 - Jun 2020

• Issue verbal and written authorization- all types : IP, OP, Dental, Pharmacy (Direct billing, Reimbursement, Guarantee of Payment) • Attend phone calls and responds to queries from beneficiaries, brokers and providers about coverage and limitations. • Assess all types of pre-approvals, requests policy-wise in accordance to the benefits limit, previous claims history, previous approvals and medically-wise.• Encoding details of pre-authorized claims in AIMS• Evaluate the medical necessity of the requested service according to the medical data provided and accurately code the service description stated on the prior authorisation requests, based on accepted medical coding rules, medical guidelines and policy’s schedule of benefits• Ensure that proper documentation of the data including business decisions are correctly done on the system with focus on accuracy, efficiency and quality• Constantly work on improving the turnaround time and relevant functional and personal competencies• Ensure that the medical ethics are applied and respected at all times while performing duties and responsibilities• Report suspected cases of fraud and/or abuse by the healthcare providers to respective Supervisor• Handle changes in the work load flow from healthcare providers in terms of time, quantity and type of prior authorisation requests received with a clear focus on both quality and set target• Ensure that cases that need Case Management intervention are escalated based on the communicated criteria• Process high cost pre-authorisation request in line with the high cost authority matrix• Support the company’s decisions while keeping the company professionally represented at all times Show less

Medical Intern

• Jun 2011 - May 2012