Sara Abd El-Hameed Mahmoud

Senior Of Claims and CollectionFull Time

Medical Claims AuditorFull Time

• Job Details:• Working as Auditor for 5 Insurance Companies (Inaya Misr, Egycare, Wadi El-Nile, Nextcare Health and MetLife). • Perform technical audit on medical claims . Justify the rejection reasons on system in rejection cases to facilitate the reconciliation process. Proper implementation of agreements on claims in collaboration with the audit and processing team • Audit of invoice, if it is under his job responsibilities. • Coordination with other adjusters for distribution of the claims • Escalation of any problematic area to direct manager. ⚫ Formulate and handle exceptions of claims. • Individually monitors, analyzes and reports claims information including relevant health care trends and high cost claims by segment. • Work with Plan departments to develop and oversee standard operating procedures to ensure consistency in business rules applied in claim adjudication. ⚫ Review claims, hospital bills, and physician notes and data to devise and refine procedures for identifying and resolving billing errors and provider billing practices. • Work with the health plan provider team and the auditing team to develop ongoing processes for auditing provider bills, recording errors and tracking collections. • Work closely with data analysts, clinical operations, technical, legal and operational teams to create sustainable cost savings solutions. • Perform variance analysis, assists with medical claims reconciliation and payment process development/improvement. • Publish various reports and presentations. • Aligns with fraud waste and abuse reduction initiatives and leading resultant initiatives and projects. • Expand the scope of payments reviewed by using data analytics to find new opportunities. • Develop or expand performance metrics to assess the quality of our payments and their improvement over time.

Medical Call center ApprovalFull Time