Nilesh Shah personal email
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Medical Claims Adjudicator, Coder, Reconciler, and Auditor with 13 years of experience. Certified by AAPC as CPC and CPMA and by LOMA as FLMI and ACS.My areas of expertise include:Medical Claims Coding• Proficiency in evaluating ICD 10, CPT, CDT, Per-dim, service codes, DRG codes, DRG severity, add-ons, and outliers. • Proficiency in evaluating NCCI edits, MUE, upcoding, unbundling, and over-billed consumables.Medical Claims Audit• Perfect review of patients’ files.• Proficiency in evaluating medical histories, clinical procedures, test reports, prescriptions, discharge summaries, OT notes, invoices, and receipts. • Review of claims on Excel and Power BI. Patterns recognition. SQL data extraction.• Skills in written and verbal communication.Medical Claims Adjudication• Specialized in reimbursement claims, direct billing IP and OP claims (DHA and HAAD), the rest of Gulf OP/IP claims, dental claims, pharmacy claims, and alternative benefit claims.• Robotic processing of PPO claims.• Auto-adjudication of PPO claims (CEED software evaluation and processing of claims).• Provide customer service pertaining to claims-related inquiries received from network providers, brokers, and insured members.Claims Reconciliation• Analyze claims and rejection rates on Excel.• Communicate with providers about payable amounts and claims-related remarks. • During the negotiation process, the payable amounts and yearly sign-offs are agreed upon.Data Analysis and Visualizations• Solid skills in Power BI, creating DAX measures and dashboards, and analyzing data.• Proficiency with Excel 365, specifically dynamic array spill formulas, single cell reporting, pivot tables, charts, macros, power query, power pivot, and style formatting.• Microsoft Office 365 apps include Word, PowerPoint, Outlook, Publisher, OneNote, Forms, Visio, Whiteboard, SharePoint, Teams, and Access skills.Individual policy underwriting (HAAD, DHA and North Emirates policies).Experience in general medicine, surgery, paediatrics, obstetrics and gynaecology, ICU, and NICU.
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Medical Claims OfficerMetlife GulfDubai, Ae
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Medical Claims AdjudicatorMetlife Gulf Aug 2015 - PresentDubai, United Arab EmiratesAdjudicate Reimbursement claims through claims management software using ICD, CPT, HCPCS, DRG, CDT and service codes: I review medical histories, clinical procedures, test reports, prescriptions, discharge summaries, invoices and receipts to process the reimbursement claims based on TOBs and R&C rates (or factors for HAAD policies). Many times, I investigate fraudulent claims. I adjudicate 65 claims per day.Adjudicate PPO Claims through claims management software: DHA claims OP and IP, HAAD claims OP and IP, Gulf claims OP and IP, IP claims from India, Lanka, and Philippines are reviewed and adjudicated. Entry errors, copay and coinsurance errors, Fee-table errors are corrected. Pre-approvals/PBM IDs are verified. CPT justification and CPT upcoding are examined. NCCI edits are reviewed for unbundling. MUE units are verified. Over-billed consumables are deducted. The DRG codes and Severity are assessed on 3M. DRG add-on and outlier calculation are verified. The target of 425 OP claims and 40 IP claims per day is exceeded.Pre-approvals and PBM Support: each request is reviewed for differential diagnosis, past medical history, justification for the tests and procedures, exclusions, policy sub-limits, and contractual tariff. Each request is reverted with remarks within 60 minutes. PBM support (and overriding) are provided to pharmacies.Provide customer service pertaining to claims-related inquiries received from network providers, brokers, and insured members.Review of Resubmitted PPO claims: providers’ comments reviewed, adjudication errors corrected in the claims, robotic reprocessing of the claims done, and remittance advice uploaded on the E-portal.Reconciliation of PPO claims: contested claims are reviewed in Excel. Claims-related remarks and payable amounts are communicated to the providers. During the negotiation process, amount payables and signoffs are agreed upon. The annual target of 75% of total $ value achieved.
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Managed Care ExecutiveAl Sagr National Insurance Company (Asnic) Aug 2013 - Aug 2015Dubai, United Arab EmiratesReview reimbursement claims coded with ICD9/ICD10, CPT, DRG, HCPCS, drug, dental, and service codes: I review the claim forms, test reports, prescriptions, discharge summaries, original invoices, and receipts to process reimbursement claims on TATSH software based on UCRs, TOBs, and exclusions.Review direct billing claims (Eclaims and hard copies) within the due dates: I review Eclaims and paper claims received from Nextcare, NAS, and Inayah TPA. Once I authorize the claims on ASNIC medical software, payments are made to the providers. I frequently generate reports for outstanding claims, and settled claims, auditing errors, providers’ payments, turnaround time, and late submissions. In OP claims, common errors include claim duplication, missing pre-approvals, over-billing, over-investigations, omitted coinsurance, and late submission. In IP claims, common errors include incorrect CPT codes, extra CPT codes (unbundling), DRG codes with higher severity, and additional HCPCS charges. Overbilling of medications and submission of PBM denied claims are typically detected in pharmacy claims. The claims for individual policies must be checked for any undeclared medical conditions.Attend to claims-related inquiries received from brokers and members: I liaise with Nextcare, NAS, and Inayah TPA to resolve queries and errors encountered in medical claims and pre-approvals.Individual policy underwriting (HAAD, DHA, and NE policies): I review declaration forms, medical reports, test results, and previous year’s claims to determine premium loadings on ASNIC medical software.I have experience working with HAAD and DHA policies. I have experience working with Abu Dhabi and Dubai network providers. -
General Practitioner (Locum)Al Nuaimia Clinic Jul 2011 - Aug 2013Ajman, UaeAttend the clinic in the morning and in the evening.Examine and treat medical illnesses and injuries. Perform minor surgeries and therapeutic procedures, including IV fluid therapy, nebulization, vaccination, interpretation of ECGs and X-rays, and collecting blood samples.A gate-keeping service provided to Gulf Eternit, Dubai Security Group & Sheraton Deira.Approving medical claims for Global-Net TPA.
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Medical Claims ApproverVidal Jul 2011 - Aug 2013Dubai, United Arab EmiratesReview direct billing claims submitted by network providers: Eclaims and paper claims are already uploaded to Jupiter software. Each claim is evaluated using the following criteria: 1) Member’s name, card number, product ID, and validity period 2) Correlation of diagnosis, tests, and treatment (medical necessity) 3) Previous claims history in the last 60 days (follow up and duplication if applicable) 4) Network tariffs and discounts 5) Deductibles and coinsurance 6) Limit and sub-limit 7) Preparation of payment orders 8) Identification of medical abuse, fraud, and overcharging 9) Review of CPT codes based on discharge summary and test reports.Review reimbursement claims according to the TOBs and network tariffs (UCRs).Authorize PBM approvals: override any incorrect denials on PBM.Authorize medical claims pre-approvals (inpatient and outpatient): Each pre-approval request is reviewed according to the following criteria: 1) Name, card number, validity, product ID 2) Symptoms, signs, differential diagnosis, past medical history 3) Tests and procedures requirement 4) Exclusion if applicable 5) Sub-limit if applicable, and 6) Network tariff. Written approvals or denials are issued through Jupiter software. -
Registered NurseMammut Technocrete Mar 2010 - Mar 2011Dubai, United Arab EmiratesFirst aid and emergency care for major injuries and medical emergencies.Provide CPR using an AED, oxygen therapy, immobilization, basic trauma life support, glucose testing, administering ASA, NTG, salbutamol nebulization, IV glucose, and adrenalin.Examine medical illnesses and refer patients to appropriate clinics and hospitals.Manage the factory clinic, and maintain the stock of all consumables and non-consumables.Check and interpret medical bills received from the pharmacies and clinics before paying them.Report all the injuries to the safety officers for their preventive measures. -
Registered NurseJa Resorts & Hotels Oct 2008 - Mar 2010Dubai, United Arab EmiratesWorking with guests: emergency care, first-aid, referral to private clinics and hospitals, performing CPR using an AED, reporting food-related illnesses and related food-handlers, reporting recreational illnesses related to pools and beaches, gyms, and spas. Working with hotel employees: examining sick employees, referring them to government or private clinics and hospitals, investigating food-related illnesses (e.g., gastroenteritis, skin infections, RTIs, skin lesions), reporting to HR manager for illnesses that have occurred in different departments.Expense claims reimbursement for sick staff, OHC renewal, post-vacation check-ups, visa medicals, HC renewals, and training programs.First-aid boxes & AEDs: regular maintenance & refilling, instructions for use.Manage Rota for first-aiders.Participate in training programs such as BLS and food handler basic food hygiene courses.Arrange OHC renewals and post-vacation check-ups at Dubai municipality; arrange HC renewals.Arrange visa medical check-ups at government clinics. Hotel clinic maintenance. -
Registered NurseInternational Electro-Mechanical Services Co. Llc May 2006 - Jun 2008Dubai, United Arab EmiratesExamine and treat medical illnesses during the morning and evening shifts.Visit remote labour camps twice a week to provide medical care.In case of a medical emergency, provide emergency care and observation.Refer sick laborers to physicians/government hospitals and follow up on their condition thereafter.Check medical bills from pharmacies and clinics for reimbursement.First-aid and emergency care at the Business Bay Lake hotel construction site. -
Registered NurseArabtec Construction Jun 2005 - Feb 2006Burj Khalifa, Dubai, United Arab EmiratesProvide emergency and first-aid care for major injuries and medical emergencies.Accompany the patient in an ambulance from the construction site to a hospital.Provide CPR with AED, oxygen therapy, immobilization, basic trauma life support, glucose testing.Administer - ASA, NTG, nebulization, IV glucose, and adrenaline.Provide medical care for minor injuries and medical illnesses.Teamwork with safety people and engineering managers. Inform safety officers about injuries to ensure work related preventative measures take place. -
General PractitionerGp Clinic Nov 2002 - Apr 2005Mumbai Area, IndiaDiagnose and treat medical illnesses and injuries. Performing minor surgery and therapeutic procedures, including IV fluid therapy, insertion of a Foley’s tube and a naso-gastric tube, nebulization, vaccination, interpretation of ECGs and X-rays, collecting blood samples, and CPR.Treat common neonatal and paediatric problems.Treat common gynaecological and obstetric cases; monitor diabetes and hypertension cases. Referral to a super specialty for a second medical opinion or admission.
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Resident Medical OfficerKamran Nursing Home Nov 2002 - Apr 2005Mumbai Area, IndiaDuring the absence of a physician, to carry out the responsibilities of that physician.Monitor admitted patients and provide necessary care. Interact with the nursing staff.Admission of medical cases and initiation of IP treatment.
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Resident Medical OfficerSaikripa Children'S Hospital Nov 2002 - Apr 2005Mumbai Area, IndiaExamine and treat OPD patients.Admit and initiate treatment for IPD patients.Monitor admitted patients; Provide emergency care when needed. Interact with nursing staff.
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Resident Medical OfficerHegde Hospital Nov 2002 - Apr 2005Mumbai Area, IndiaMonitor pre-operative and post-operative cases, supervise nursing staff, and maintain the unit.Assist in minor and major surgeries. In the absence of a general surgeon, perform minor surgery.Examine surgical and orthopaedic OPD patients. Provide care for surgical emergencies, orthopaedic cases, and labour cases.Prepare and maintain OT, sterilize articles, and manage stock levels.
Nilesh Shah Skills
Nilesh Shah Education Details
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Bachelor Of Science In Nursing -
Bachelor Of Ayurvedic Medicine And Surgery
Frequently Asked Questions about Nilesh Shah
What company does Nilesh Shah work for?
Nilesh Shah works for Metlife Gulf
What is Nilesh Shah's role at the current company?
Nilesh Shah's current role is Medical Claims Officer.
What is Nilesh Shah's email address?
Nilesh Shah's email address is dr****@****hoo.com
What schools did Nilesh Shah attend?
Nilesh Shah attended Mangalore University, University Of Mumbai.
What are some of Nilesh Shah's interests?
Nilesh Shah has interest in Medical Practice, Medical Claims.
What skills is Nilesh Shah known for?
Nilesh Shah has skills like Management, Data Analysis, Microsoft Word, Ms Excel Pivot Tables, Ms Access 2010, Microsoft Excel, Medical Practice, Customer Service, Medical Management, Insurance Claims.
Who are Nilesh Shah's colleagues?
Nilesh Shah's colleagues are Drashti Buddhdev, Wafi Algousi, Nhica Lyn Degollacion, Bsn-Rn, Fcs, Almi, Ahmed Ismail, Mohsin Rasheed, Donald Gatan, Shimshon Chariker.
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Nilesh Shah
Director Specializing In Manufacturing Engineering At Fluid Pumps & Equipment India Pvt. Ltd.Dubai, United Arab Emirates -
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