Orthopedic surgeon with specialization in hemophilia and another congenital blood disease, with more than 17 years as medical doctor. More than 9 years of international experience in training and coaching of sales teams for pharmaceutical industry. Solid experience as speaker in muscle-skeletal issues in hemophilia and pain, professor in orthopedics for postgraduate residents, educational meetings to patients and healthcare providers. Medical translator from English to Spanish. Actual Job Description:To scrutinize in a professional manner medical claims (both reimbursement and direct billing) and to provide prior approval for medical treatment. Liaise and negotiate with the medical providers to ensure the validity of the treatment as per the insurance policy terms and conditions and to ensure that prices are in line with those agreed for Network providers or remain “reasonable and customary” for non Network providers. Responsible for effective communication with the insured client in order to explain the covers and answer any specific question related to a given claim.Main Accountability:• Handle relations with the medical providers which includes negotiating all the discounts, studying all the price lists, handling reconciliations and visit the Medical Providers on a regular basis;• Analyse prior-approval requests, negotiate the cases with the medial providers, approve the cases when agreement is reached and enter the claim into IT system;• Supervise In-patient claims (this supervision includes visits to the patients during their hospitalization);• Advise on Medical Basics and Practice;• Assist Medical Claims Administrators in processing claims;• Validate all medical claims in IT system;• Communicate with Insured Members on their claims and on any request coming from an Insured Member• Ensure that all medical information is kept confidential.