Omar N

Medical Claim Officer - Allianz Care

Oct 2025 - Present • 11 mos

Review, assess, and process medical insurance claims in compliance with company policies and international standards. • Verify medical documents, invoices, prescriptions, and coverage eligibility. • Ensure accuracy, completeness, and legitimacy of submitted claims. • Coordinate with hospitals, clinics, medical providers, and global partners. • Apply policy terms, exclusions, and benefit limits correctly. • Detect potential fraud, inconsistencies, and irregular claims. • Handle customer and provider inquiries professionally and efficiently. • Maintain accurate claim records and documentation within internal systems. • Meet service level agreements (SLAs) and performance targets. • Experience handling U.S. medical claims and local insurance cases. • Strong knowledge of U.S. insurance systems, including Aetna, Medicare, and Medicaid. • Familiarity with U.S. healthcare providers’ billing systems, coding standards, and claim adjudication processes. • Proficient in medical coding systems, including CPT and ICD-10. • Ensure high coding accuracy and compliance with international medical coding guidelines. • Experience in claims auditing and quality assurance processes. • Skilled in denial management and resolving rejected or disputed claims. • Ability to analyze claim discrepancies and recommend corrective actions. • Maintain confidentiality and compliance with healthcare data regulations (e.g., HIPAA).

Call Center Officer - Nextcare TPA

Aug 2021 - Oct 2025 • 4 yrs 2 mos

Medical Assessment and Approval: • Reviewed and evaluated medical claims and requests for treatments, medications, and procedures. • Ensured medical necessity and compliance with policy guidelines before approving claims. • Collaboration with Healthcare Providers • Keeping in touch with hospitals and other healthcare providers to verify the appropriateness of proposed medical services. • Provided guidance and support to healthcare providers on insurance policies and coverage details. • Patient Advocacy: • Advocated for patient needs while balancing cost efficiency and effective healthcare delivery. • Assisted patients in understanding their insurance coverage and navigating the claims process. • Documentation and Reporting: • Maintained detailed records of claims assessments and decisions. • Generated reports on approval trends, common issues, and areas for policy improvement. • Policy Development and Updates: • Contributed to the development and revision of insurance policies and procedures. • Kept updated with the latest medical guidelines and insurance industry standards. • Training and Development: • Participated in continuous professional development to stay current with medical and insurance advancements.