Shahana Raza

DR SHAHANA RAZA
M.B.B.S.
PG Diploma Healthcare Management (U.K.)
Certified Professional Coder (CPC)

Email: [email protected]
PROFILE: A highly motivated medical professional with extensive experience of the Healthcare
Industry and medical insurance in U.A.E. Through over 17 years of experience key areas of expertise
include Claim management, contract management, corporate relations, and cost management. Has
achieved business goals by instituting new practices, cementing healthy relationship with key
accounts, and efficiently leading the workforce towards the organization goals.

QUALIFICATIONS:
Bachelor of Medicine and Bachelor of Surgery [M.B.B.S]: Sindh Medical College, Karachi, Pakistan-2002
Post Graduate Diploma in Healthcare Management: EduQual, U.K. – 2018
Certified Professional Coder: AAPC – 2021
SUMMARIZED EXPERIENCE: (3 ORGANISATIONS – 17 YEARS)
Organization: VIP Doctor LLC
Head of RCM Department
Duration: July 2023 till date
Reporting line: Facility CEO
Role: Operational, Strategic, Contract Management, Claim Management, Business Development
Organization: Dar Al Kamal Hospital
Head of Insurance Department
Reporting line: Hospital COO
Role: Operational, Strategic, Contract Management, Business Development
Duration: May 2021 to Oct 2022
Organization: Prime Healthcare Group (6 years – exponential growth)
Manager Group Insurance Network – 24 clinics, 1 hospital, 16 pharmacies
Duration: Jan 2015 to April 2021
Reporting line: Director Revenue Cycle
Role: Strategic, Contract Management, Business Development
Organization: Al Buhaira National Insurance Company (9 years – exponential growth)
Head of Network Department (Head Office)
Duration: Sept 2005 to Dec 2014
Reporting line: Manager – Life & Medical Dept
Role: Operational, Contract Management, Revenue Cycle Management

DR SHAHANA PROFILE 2023
DETAILED WORK EXPERIENCE & KPI’s
VIP Doctor LLC:
• Primary focus on planning and implementation of Policies & system.
• Facilities management rules while leading a multidisciplinary team including financial analysis,
problem solving.
• Serve Insurance clients as per the guideline designed by the Insurance / TPA with support of
Health authority.
• Manage & prioritize claims workload through continuous assessment, assistance, and staff
management.
• Facilitate inter departmental communication, negotiation and decision making.
• Maintain MIS, KPI’s, process flow and Dashboard for the senior management.
• Submit monthly ageing on re-submission and denial analysis to management.
At Dar Al Kamal Hospital: (1.5 year)
• Implement the Insurance policies after the agreement with Insurance and educate the team
and relevant stake holders on protocols & policies.
• Manage & prioritize claims workload through continuous assessment, assistance, and staff
management.
• Ensure proper accounting of credit bills and monitor the amount received from Insurance on
a periodical basis.
• Consolidate the monthly billing statements with Insurance claims, review the status of any
outstanding bills every month and ensure that such outstanding payments are collected from
Insurance.
• Maintain MIS and Dashboard for the senior management.
• To ensure that all the Insurance contract are managed efficiently and reviewed periodically.
• Submit monthly ageing on re-submission and denial analysis to management.
• Review and audit high-cost claims before submission to Insurance.
• Ensure efficient customer service & satisfaction by providing prompt response to queries.
At Prime Healthcare Group: (6 years)
• Identify prospective insurance companies & TPA’s and finalize billing agreements.
• Maintenance and updating of master tariff list.
• Manage and improve front desk, billing, and insurance processes.
• Regular training and inter-department educative sessions.
• Manage internal & external insurance communication.
• Price analysis, benchmarking & timely revision of prices with Insurance companies.
• Manage DHA compliance related to network functions.
• Coordinate with insurance claim submission team.
• Identify of opportunities for process improvement & development of new programs.
• Consolidate and analyze monthly reports.
• Ensure that service culture is promoted.

DR SHAHANA PROFILE 2023
At Al Buhaira National Insurance Company: (9 years)
Network related (3 Years)
• Provider Network development by analyzing the market and health plan needs.
• Managing contractual relation including prices reviews and range of services.
• Re-assess & re-negotiate existing contracts in accordance with utilization.
• Ensure efficacy of network processed by provider education.
• • Monitor medical providers for abuse.
• Attend DHA meetings, trainings, and workshops.
• Update all internal departments on the evolving regulatory requirements.
Claims & Approval related (6 years)
• Effective case management in case of in-patient treatments and large loss cases.
• Maintain required turn-around-time for worldwide pre-authorizations & evacuations.
• Arrangements for overseas referrals, evacuations, appointments etc.
• Meeting the doctors and clients to discuss the cases and treatments options.
• Analyze and appropriately respond to in-patient and overseas approvals.
• Analyze the Approval as per the policy term, conditions, and exclusions.
• Review settlement of complex, large loss, and contested cases.
• Identify the cases requiring second opinion.
• Maintain communication with TPA and clients.
• Maintain check on claim abuse and medical negligence.
• Determine reasonable and customary costs for local and international treatments.
• Provide support to various organizational functions – Underwriting,
Customer Service, Finance & Marketing,
• Assessment and Processing of paper claims & e-claims.
• Suggest methods of cost control
• Liaising with providers, for all the necessary information regarding Claims and Approval.
• Training to all the new staff regarding the claim and approval processing.
KEY SKILLS & KNOWLEDGE:
• Excellent knowledge and understanding of medical coding and E-claims
• Excellent communication and negotiation skills.
• Understanding of financial and operational issues.
• Effective process improvement and problem resolution skills.

CLINICAL EXPERIENCE:
• Registered Medical Officer (RMO) – Memon Medical Complex in Karachi.
• Medical Officer (Gynecology & Obstetrics) – Jinnah Post Graduation Medical Centre, Karachi.
• Medical Officer (Radiology) – Jinnah Post Graduation Medical Centre, Karachi.
PERSONAL INFORMATION:

Marital status: Married Visa Status: Employment Visa
Languages: English, Hindi, Urdu U.A.E. Resident since: 19 years
Reference: On request