DK

Dr. Khalil Fathy Khalil Abu Jamea

Medical Insurance Director | TPA Operations & Claims Governance | Fraud & Compliance | CHI | MBBS + IFCE | 12 Yrs KSA

Dammam, KSA
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6

Companies

13

Skills

3

Certs

5

Highlights

About

Medical Insurance Director with 17 years in TPA operations, claims governance, and fraud mitigation across the Saudi health insurance sector. Has overseen annual claims exposure in the SAR 20M-50M range, managing adjudication accuracy, cost containment, and CHI regulatory compliance across provider networks of 50+ facilities. An MBBS background adds clinical depth to insurance decisions.

Key Highlights

  • CLAIMS OVERSIGHT: Directed roving claims operations across 50+ provider facilities, managing an estimated annual exposure of SAR 20M-50M while maintaining full CHI compliance and cost containment controls.
  • TEAM LEADERSHIP: Led a team of 10+ claims reviewers, consistently meeting SLA turnaround targets and cutting escalated case volume through targeted performance improvement plans.
  • TRAINING & DEVELOPMENT: Designed and delivered structured onboarding programs that reduced new-hire ramp-up time by an estimated 30% and improved adjudication accuracy across the team.
  • FINANCIAL REPORTING: Managed full-cycle claims adjudication at Al Sagr Insurance - covering an annual exposure of SAR 20M-50M - and prepared detailed exposure reports that supported leadership decisions on reserves and provider negotiations.
  • FRAUD REDUCTION: Contributed to building fraud risk indicators at Al Rajhi Takaful that helped reduce fraudulent claim approvals through structured site audits, investigation workflows, and compliance team coordination.

Skills

Medical Claims AdjudicationClaims Governance & AdjudicationPre-Authorization ReviewInpatient & Jumbo Case OversightICD-10 & CPT Coding FamiliarityFraud Detection & InvestigationCHI Regulatory ComplianceTPA Operations ManagementProvider Negotiation & RelationsCost Containment StrategySLA & KPI ManagementData Analysis (Advanced Excel)Team Leadership & Training

Experience

Roving Team Leader

Total Care Saudi (TCS TPA)

05/2024 – 12/2025

  • Directed roving claims oversight across a wide provider network of 50+ facilities, ensuring 100% adherence to medical necessity criteria and contractual compliance with CHI standards.
  • Designed and delivered structured onboarding and training programs, reducing new-hire ramp-up time by an estimated 30% and improving team adjudication accuracy.

Claims Analyst

Total Care Saudi (TCS TPA)

12/2023 – 05/2024

  • Conducted end-to-end audits of claim files across inpatient and outpatient categories, ensuring full regulatory and contractual compliance.
  • Reviewed high-value inpatient cases for medical necessity and documentation integrity, preventing overpayment on complex cases.

Medical Claims Controller

Al Sagr Insurance

12/2020 – 11/2023

  • Managed full-cycle claims adjudication for a portfolio including complex, chronic, and high-cost inpatient cases; monitored and reported on annual claims exposure in the range of SAR 20M-50M, enabling leadership to make timely reserve and negotiation decisions.
  • Prepared detailed financial exposure reports for leadership, enabling data-driven decisions on reserves and provider negotiations.

Senior Specialist – Roving & Fraud Detection

Al Rajhi Takaful

05/2020 – 11/2020

  • Conducted hospital site audits and high-risk claim reviews, flagging suspicious billing patterns and initiating investigation workflows.
  • Collaborated with compliance and audit teams to implement corrective actions that reduced fraudulent claim approvals.

Fraud Detection Executive

Al Rajhi Takaful

07/2019 – 04/2020

  • Analyzed abnormal utilization and billing behavior across provider network.
  • Contributed to development of fraud risk indicators used to flag high-priority case reviews.

Insurance Physician

Al Mana Hospitals

10/2017 – 06/2019

  • Evaluated and authorized inpatient treatment plans for insurance coverage alignment, bridging clinical and insurance functions.
  • Coordinated between clinical teams and insurance departments to improve case processing and reduce authorization delays.

Medical Case Management & Provider Support Officer

Medgulf

03/2014 – 09/2017

  • Managed pre-authorizations, eligibility verifications, and coverage clarifications for a high-volume caseload.
  • Provided 24/7 escalation support for complex medical approvals, ensuring continuity of care and policyholder satisfaction.

Pre-Authorization Medical Specialist

Sanad

05/2013 – 11/2013

  • Processed pre-authorization requests and eligibility verifications in alignment with policy terms and CHI guidelines.
  • Supported provider-insurer dispute resolution and coverage decision clarifications.

Certifications

Insurance Fraud & Compliance Executive (IFCE)

2017

Anti-Fraud in Insurance

The Financial Academy, Saudi Arabia · Sept

Data Analysis with Advanced Excel

Nove

Education

University of Science and Technology, Sana'a

Bachelor of Medicine & Bachelor of Surgery (MBBS) in Bachelor of Medicine & Bachelor of Surgery (MBBS)

2009

Languages

ArabicNative
EnglishFull Professional

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