Health Insurance Expert

• Major: Homeopathy

Medicine and surgery

Guardian Insurance Brokers LLC, Abu Dhabi, UAE
Team Leader
Scrutinizing and sanctioning the proposals put up by the team for Group Life renewals, while suggesting the modifications, if any, to match client’s expectation and secure renewals
Allocating tasks, supporting the team, supervising overall functions of processes handled, identifying the areas of improvement and executing apt measures to enhance customer satisfaction
Working closely with the business partners, also ensuring compliance with all regulators guidelines (HAAD, DHA and Insurance authority)
Monitoring the tracking sheets & key performance indicators on weekly basis to make sure the delivery of high quality service
Adhering to the standard processes and procedures as per the workflow, ensuring complete documentation, originating ideas to improve services, organizing periodic meetings with clients and insurance companies
Resolving the challenges / client complaints, highlighting unresolved issues to department manager, also providing him feedback on market trends, customers, retention, regulations, and any other relevant information
Being up-to-date with current regulations & laws regarding the insurance industry

Assessed the medical necessity and consistency of diagnosis / procedure / drug codes and descriptions stated on the claims to the accepted medical coding rules and guidelines, daily targets, quality, and other key performance indicators (KPIs)
Supervised routine daily claims administrative work consisting of the deptt / Submission / Resubmission / Auditing and reporting to the manager on monthly basis
Enhanced and executed the guidelines pertaining to evaluation / processing / policies / procedures and work-instructions related to medical claims
Decided on high cost, rejected and complicated cases on commercial and medical grounds with payers
Performed internal quality checks to evaluate submission of information by team in line with schedule of benefits / deductibles / co-payments / observance of policy limits and adherence to claims submission protocols, also overseen the timely documentation & communication about business decisions & processes by the team

Projected & incorporated the requirements of partners with business operations
Monitored the relationship and business portfolio by recurrent follow-up / meetings
Sent doubtful / fraud cases from Insurance companies and TPA for verification and investigations
Scrutinized the medical and non-medical claims basis on the evidence based report provided by TPA & Insurance companies
Conducted frequent meetings and audit of the claims as well as authorization teams of various TPA’s associated with the project in different states on national levels
Prepared the claims flow and performance report of Providers / Vendors affecting the claims

Reviewed applications basis on the set criteria, also analyzed the recommendations from underwriting software such as Life Asia
Restructured the process of auditing & initiated physical visits like mystery shopping
Analyzed the risk by synchronizing with sales force, medical personnel and other team members and acquired relevant and complete information, also accepted / rejected the claim applications in accordance to the compliance and set standards
Safeguarded company’s profitability by adequately deciding on the premiums and coverage to support sales staff

Conducted precise and well-timed audits of claims adjudged and sanctioned by medical team members
Updated clients, members, provider escalations on claim status, benefit designs, and claim payments while operating with the Customer Service Representative
Evaluated high value authorization request to recheck the eligibility and highlight the debatable area to management, if any, with complete and accurate information
Processed claims according to medical coding rules / guidelines and adhering to the ICD9CM/ICD10CM codes appropriately
Handled routine claims and daily administration work efficiently while achieving the daily targets

Other certificate

Other certificate