Operations Director (BPO / TPA / Healthcare / Insurance / Claims)
SEHA TPA (Aetna / GlobeMed), Qatar
SEHA TPA is contracted to administer healthcare benefits offered by the State of Qatar to its nationals. Reporting to the COO, and tasked with strategically reviewing, structuring, streamlining, and increasing discipline to elevate productivity and service delivery to the next level. Full KPI and SLA responsibilities. Handling approx. 200,000 eClaims per month from a network of 220 direct billing providers; leading team of 50+ staff comprising Doctors, Nurses, Dentists and Claims Assessors along with Medical Coding and Network Professionals. Joined under challenging circumstances with KPI and TAT indicators under pressure. Effected turnaround around within 5 months following planned and integrated change.
- Strategic review of operations, identifying quick wins, integrated and multifaceted change, and a transformation roadmap.
- Designed and launched reporting dashboard, tracking key metrics against team and individual performance objectives and providing insightful business intelligence.
- Redesigned organisation, effected a high-performance culture, and established clear accountabilities across the team.
- Developed evidence-based forecasting and capacity models to align headcount to volumes, and to ensure realistic targets for team members.
- Devised and implemented strategies to strengthen policy, procedure, controls, and employee capabilities.
- Collaborating with third-party consultants from Accenture, adopted risk-based approach to mitigate control deficiencies and improve claim review consistency.
- Streamlined process, systems, increased automation using rules based technologies:
- Achieved 78% auto-adjudication in Dec 2015, and improved processing accuracy.
- Secured ongoing Turn-Around-Time reductions from 20 to 16 days in Claims.
- Collaborated to establish QA organisation, aligning independent Quality assessments in Claims and Provider Relations to individual performance management.
- Core member of client management team, and participant in regular governance and proposition development discussions.