DR.MAMOON YUNUS
drmamoonyunus@gmail.
com
Sharjah, UAE
Mobile : +971551482194
Job Title: Insurance Manager-Medical
STARWELL NETWORK MANAGEMENT LLC DUBAI-03rdMarch 2016 to Till Date
Responsibilities:
 .Claims processes. Adjudication, verification as policy terms and condition.
 Approval request processing (OP&IP)
 Related the prices of every procedure according to the assigned CPT code thereby ensuring the
proper billing process in the company for the providers
 Checking the CPT& ICD code to ensure proper treatment.
 Correspondence with member, provider, insurance companies and broker regarding complaints and
his inquiries
 Handling help lines calls system
 Claim analysis, analyzing policy performance and loss ratio for all policy monthly bases
 Reimbursement claims (OP&IP) from UAE and Indian subcontinent evaluate and settlement as per
policy guide line
 Empanelment clinic, pharmacy, diagnostic centre and hospitals. Tariff negotiations
 Preparing fraud, waste and abuse report on quarterly basis
 Re-orientation program for clients for explaining table of benefit and protocol of use of
insurance card
Job Title: Assistant Manager–Medical
STAR WELL HEALTH MANAGEMENT FZC LLC Dubai – 9
thJanuary 2014 – 02ndMarch 2016
Responsibilities:
 Process OP&IP request within TAT and as per policy guide line.
 Checking the eligibility, medical necessity of service determinate the services are covered as per
insurance policy and condition, preparing Fraud waste& abuse report
 Reviewing the status of request and updating the concern department about the status of request
whether approved, denied, query or require more details for further processing
 Answering all patients queries, related to insurance –pending approval, network, co-payment,
eligibility and insurance card policy
 To settle all claims on daily basis and following up pending approvals and dispatch them to finance
and ultimately to insurance companies
 Liaising with insurance company ,brokers and provider
 Handling network department reviewing and updating the price list
 Handling complaints and grievances of customers, insurance companies and provider
 Handling Reimbursement claims from UAE and Indian Subcontinent as per policy guide line.
 Checking the CPT& ICD code to ensure proper treatment
.

Job Title: Assistant Manager–Medical
GENINS INDIA TPA LTD - BHIAR –– 15 July 2010 – 30 November 2013
Responsibilities:
 Management of claims from Network hospital
 Processing Reimbursement claims and preauthorization as per policy terms and condition.
 Scrutiny of Query replies of claim and drafting denial letters
 Prioritization of platinum customer (hospital and corporate both) for cashless as well as claims.
 Contact insured or other involved person for obtains missing information.
 Visit to hospital for investigation of Medclaims and check claims record and IP and OPD register,
cash memo
 We are looking Mass policy(RSBY)in Bihar which policy governed by government of India and state
government
 Empanelment and de-empanelment of the hospital for RSBY as per criteria
 Liaison with insurer, state nodal agency, CMO, various NGO, department of labor& health in state
and smart card vendor
 Post hospitalization investigation of RSBY claims
 Price review and cost saving
Job Title: Medical claim Officer
MEDI ASSIST INDIA PVT INDIA TPA –– 2
NDNOVEMBER 2009 –11 JULY 2010
Responsibilities:
 Processing Reimbursement claims and preauthorization as per policy terms and condition.
 Looking to client grievances and solve their problems to complete satisfaction.
 Taking care of claim coordinators, call centre executives keeping records of the
grievances, data entry operators’ entering the bills.
 Coordinate with different hospitals all over India which are in our panel.
 Improve scrutiny methods to trigger investigation of fraudulent claims
 Auditing and filtering the all medical aspects of insurance claims documents before processing
Job Title: Medical claim Officer
E-MEDITEK SOLUTIONS LTD–– 24THMAY 2008 – 1
ST NOVEMBER 2009
Responsibilities:
 Claims management –authorization, adjudication, verification, audit as per policy terms and
condition
 Scrutiny of query replies of claim and drafting denial letters,
 Claims investigation as per policy terms and condition
 Hospital investigation and patient verification
 Reimbursement claims process and settled as per TAT
 Fraud detection and abuse control
 Attend email of customer and insurance company and provider and its reply
Job Title: Residential medical Officer(RMO)
Life Care Hospital - Bihar–– 23THJan 2004 – 30thJan 2008
Responsibilities:
 Checking admission and discharge status of patients, co-ordinate with consultant, making
discharge summary of patient
 Arranging camp for patient and meeting with local doctors for patient referral
 Preparing medical report of the patient for insurance approval

 BUMS (Bachelor of Unani medicine &Surgery) in 2004 from Government Unani
Medical College Patna India
 Certified professional Coder (CPC) applied
Certificate and training:
IgotcertificatefromA.I.IinintermediateclaimshandlinginmonthofMay2016
OFFICE SKILLS
 M.S Office
 M.S Excel
PERSONAL INFORMATION:
 Father’s Name : Mohd Yunus Usmani
 D.O.B :19.10.1977
 SEX :Male
 Marital Status :Married
 Nationality : Indian
 Language : English, Urdu, Hindi
 Passport Number:L9526313
 Present Address : Dubai
 Visa Status : Residence Visa
Place- Dubai Dr. Mamoon Yunus