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CV
Hisham Diab Diab Ismail Mahmoud El Shazli
Egyptian – DoB December 2, 1971 – Married.
00971528854515 email: helshazli@yahoo.com
Focused, profit and result oriented Head of Operations – Medical, managing
high level corporate operations, delivering superior results, with demonstrated
operational excellence and team management capabilities. Leading 180
employees with regional and global responsibilities, able to create and
implement change and transformational behavior.
Visionary business professional, with track record for finding innovative ways
to maximize client satisfaction & retention. Managed multi-million dollar
budgets within a cost effective business model.
Enthusiastic problem-solver with keen ability to rapidly assess diverse
situational challenges, develop action plans, and lead team to meet or exceed
targeted goals. Effective communicator and relationship-builder with superior
detail orientation who gathers and imparts information effectively across all
management, department, and discipline levels and engenders collaborative
spirit, consistently resulting in extraordinary outcomes.
Career Summary
Twenty years of experience in healthcare sector in GCC & Egypt. Long
experience in Health Insurance Industry in KSA, UAE and Egypt running
company-wide operational functions, improving operating performance plus
supporting individual underwriting, sales, business development, marketing &
communication in addition of large scale projects, from inception to successful
completion, while making/executing sound short & long term decisions.
Areas of Expertise
 Performance Management
 Operational Strategy Planning
 Operational Excellence
 Budgeting & Profitability
 Competition Analysis
 Claim revenue cycle management
 Health Insurance & claim Management
 Travel Insurance & medical Assistance
 Fraud detection & prevention
 Case management & utilization review

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 Portfolio Monitoring
 Automation & system enhancement
 Different coding and billing systems
 Direct underwriting supportive function
 Cost Reduction strategies  Operational profit management
 Change Management  Organizational transformation
Operational Excellence:
As an operational professional (OPEX Blue Built trained), my role mandates
analyzing the customer needs and providing a road map for optimizing the
customer experience through operational excellence. Creating standard
operational procedures and improving the key performance indicators
describe an aspect of my main responsibility. Maintaining operationally excellent
processes and structures drives greater effectiveness and efficiency.
Team Work:
Teamwork can bring dreams into reality. Developing capabilities, organizing
tasks and encouraging a team to believe in them-selves, multiplies success
and satisfies the most demanding clients. Simply, teamwork for success is my
belief.
In managing operations with different LOBs, an effective teamwork and
system are required, supported by process excellence and leadership. All
elements will be an effective tool in providing services to a variety of
customers locally, regionally and globally. Leadership should create a healthy
environment, focused on targets with clear vision and mission. The team has
to understand the goals and should be committed to attaining them. This clear
direction on mission and purpose is essential for effective teamwork.
Workforce Management:
Over years a strong people management experience was built up through
working in different circumstances with evident people diversity. Productive
workforce that maintain high quality level is another aspect of my duties.
Operational Strategic Planning:
Through conducting operational SWOT analysis, I used to be a member of
management committee who is responsible for planning and directing an
organization's strategic and long-range goals. Conducts organizational
reviews to identify strengths, weaknesses, and opportunities and to evaluate
operational effectiveness.
Supportive to:
 Underwriting for different group policies.
 Business development and sales
 Projects and system enhancements

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Qualifications:
 Membership of Royal College of
Surgeons of England(MRCS)
2010 Royal College of Surgeons of
England
UK
 Health Care Anti-Fraud
Associate (HCFA)
2006 American Health Insurance Plans USA
 Health Insurance Associate(HIA) 2004 American Health Insurance
Association
USA
 Master Degree General Surgery(MSc) 2000 Faculty of Medicine,
Alexandria University
Egypt
 M.B.Ch.B 1995 Faculty of Medicine,
Alexandria University
Egypt
Thesis: “Parathyroid Gland Preservation during Thyroid Surgery”
Professional Experience:
Dec 12 up to
present
Head of Claims & Medical
Assistance
UAE
NEXtCARE – Member of
Allianz Group
NEXtCARE is a leading Third Party Administrator in the MENA region, with a large
providers’ network, providing different types of health insurance and medical assistance
services locally in UAE, regionally and worldwide.
I am responsible for providing health insurance services for local and regional clients at
any point of service worldwide. Services are provided through direct billing or
reimbursement basis. Business control and client service are conducted by Medical
Operations team (180 employees), who are coordinating with different service vendors,
provider networks and business units.
I am directly reporting to COO who is a member of regional executive committee. My
claims regional responsibility covers UAE, Qatar, Bahrain, Oman, Tunisia, Morocco &
Romania and it extends to KSA, Lebanon, Egypt and worldwide for medical assistance.
Responsible for:
 Large portfolio with huge GWP.
 Team 180. (medical, paramedical & non-medical / different nationalities)
 Dealing with local and regional providers.
 More than 3 million pre-certifications / year.
 4.5 million direct claim / year.
 180 k reimbursement claim / year.
 1million calls / year.
 Coordinating with Health Authorities DHA & HAAD.
Different functions of Medical Operations department:

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1. Precertification and preauthorization.
2. Direct claims review.
3. Claim reimbursement.
4. Case management
5. Utilization review.
6. Underwriting support (individual)
7. Claims communication.
8. Performance management.
9. Travel & assistant claims assessment (approvals and payment).
10.Reporting and statistical analysis.
11.Extended warranty administration.
12.Quality control and assurance.
13. Field control (roving doctors).
Objective: (cost control and client satisfaction)
 Implement, support and drive business strategy.
 Customer, supplier & employee satisfaction.
 Achieve & enhance the departmental KPIs.
 Operational process & performance improvement.
 Comply with HAAD & DHA directions.
2010-2012 Claim Operations Manger KSA
Tawuniya (NCCI / National
Company of Cooperative
Insurance)
I joined Tawuniya (National Company for cooperative insurance) on 2001. The purpose of
the Company is to transact in cooperative insurance operations. The cooperative insurance
principle includes Medical & Takaful coverages with different Takaful Products like
personal accident and medical Takaful. Medical products are built on the principle of
cooperation and mutual sharing of good or bad results. Hence schemes are tailor made
for any segment of the market according to their needs and budgetary constraints.
Tawuniya Medical & Takaful insurance staff members are comprised mostly of medical doctors
and professionals in the health industry who provide an excellent healthcare services through a
network and utilizes advanced information system for the provision of instant services with no
administrative or financial obstacles.
As a Claims Operations Manager of the medical team I was responsible for multi-unit
department (10 units) who is controlling the full medical claims’ cycle. The main
characteristics are:
 Large portfolio and huge GWP.
 Team 159 (medical, paramedical & non-medical / different nationalities)
 10.8 million direct billing claim / year.

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 144k reimbursement claim / year.
 Directly support the medical underwriting & actuarial functions.
 Reconciliation with major health care providers within KSA and GCC.
Key Objectives: Achieve performance goals, develop and enhance productivity and
quality standards, and maintain budget with the parameters set for the division.
Main Activities of Claims Operations Department: Claim intimation, data entry, claim
processing, automation depending on ICD10, medical and insurance evaluation,
settlement, and payment as per policy and procedures. This is plus signing clearances
and closing accounts with providers on quarterly base. (Dealing with claims from inside
and outside KSA).
I always ensure:
 Providing best medical services to clients through our medical staff to maintain
and extend our market share.
 Applying policy conditions and medical rules.
 Compliance to governmental regulations and recommendations CCHI & SAMA.
 Providing competitive services within targeted cost effectiveness.
2007-2009 Field Operations Manager KSA Tawuniya (NCCI / National
Company of Cooperative
Insurance)
Responsible for approval center, Top VIP service unit and three field forces. All of them
are doctors and supervised by group leaders. The field forces are covering the major
hospitals in the main regions of the Kingdom. All teams are consisting of specialist
doctors.
 Large portfolio and huge GWP.
 Team 43 (medical, different nationalities)
 2.16mn approval / year.
 Financial authority up to SAR 50k / claim.
My Key Objectives: Direct contact with major hospitals in order to provide best medical
services to clients, provide executive services to Top VIPs, improve response time per
approval, automate approval replies, control all inpatient cases, and improve field key
performance indicators (KPI). Main activities of Field Operations Department: Evaluate
all hospital admissions and provide client support at the point of services.
Combined operational experience and responsibilities related to the above
positions:
 Maintain strategic relation with healthcare provider.
 Providers’ claims trend analysis.
 Experienced knowledge of medical insurance policies.
 High level of orientation of health insurance plans in GCC, MENA & USA.

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 Design business plans parallel with the company goals and strategies.
 Create policy and procedures for my work areas.
 Capable of providing effective solutions towards high level of service.
 Set objectives for all teams with a time scale.
 Monitor KPIs periodically in relation to productivity and quality.
 Analyze trends in approvals, claims, policies, and providers’ billing.
 Apply corrective actions to keep targets on track.
 Excellent experience in automation of online claims and approvals.
 Enhance system applications and creation of new ones.
 Apply the process of automation using ICD.
 Oversee aspects related to annual budget.
 Indirect reporting to BMC (Business Management Committee) &CEO.
 Annual evaluation of employees’ performance.
 Conducting interviews to select new staff.
 Conducting training sessions for new comers and on applying new process.
 Conducting open talk seminars for providers’ representatives and clients.
 Announce new events in the medical field.
 Share in provider contracting and medical underwriting.
2006 Fraud Unit Team Leader KSA Tawuniya (NCCI / National
Company of Cooperative
Insurance)
Responsible for a fraud team including physicians, clerks and mystery shopping
members. (10 members)
My duties: Put and apply plans to prevent and detect fraud and abuse cases at the level
of providers and clients in coordination with other medical units. I had a financial annual
target to be recovered quarterly. Internal quality control was an essential part of Fraud
Unit duties.
I was a member of Fraud Review Committee (FRC) which is consisting of group leaders
of fraud units in different SBUs of the company with the VP and CEO. FRC was held
monthly for reporting and enhancement of actions against fraud in health insurance.
2004-2005 Group Leader Referral
Team
KSA Tawuniya (NCCI / National
Company of Cooperative
Insurance)
I was responsible for the medical claims processing done by a group of 7 doctors
directly reporting to me.
In referral team, I was conducting periodic meeting with around 50 major medical
providers to discuss medical and insurance rejections and recoveries and close
accounts every three months with providers after signing clearances.

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2003 Senior Medical Claim
Executive
KSA Tawuniya (NCCI / National
Company of Cooperative
Insurance)
2001-2002 Medical Claim Executive KSA Tawuniya (NCCI / National
Company of Cooperative
Insurance)
As medical claim executive I was responsible for evaluating, processing, and payments
of outpatient and inpatient medical claims after applying insurance and medical rules.
Coordination with consultants and providers was part of day to day activities.
1998 2000 General Surgery Specialist Egypt Main University Hospital
For a total three years I was a resident in general surgery department in the main
university hospital in Alexandria, Egypt. All surgical cases were our regular work with
daily surgical operations. I am well trained on all types of elective and emergency
surgical conditions and procedures. During my residency period I have completed my
Masters’ Degree in General Surgery. My thesis was “Parathyroid Gland Reservation
During Thyroid Surgery”.
1996-1997
House Officer in the Main
University Hospital
Egypt Main University Hospital
I had rounds on different specialties in medicine and surgery over a period of 12 months.
1995 Year of Graduation Egypt
Alexandria University,
Faculty of Medicine
Courses:
 Business Agility Management 2015
 Finance for non-finance professionals 2015
 Excel for Business 2014
 Portfolio Monitoring & Tools Training (Underwriting) 2013
 OPEX Blue Built 2013
 Health Organization Classification Surveyors 2005
 7 Habits of Highly Effective People 2004
 Effective Business Writing (IOB) 2003
 New Trends in Hospital Management 2001
Projects & Committees:
1. Provider Accreditation & Classification Committee.
2. Fraud Review Committee.
3. Enhancement of Fraud Detection & Prevention Project.

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4. Field Control Project as a part of Balanced Scorecard (BSC).
5. Top VIPs Service Project.
6. Member of a team who is responsible for releasing any new software
system in medical department.
7. Member of Claim Management Team (CMT).
Work Related Skills:
 See through the eyes of my customers (clients, providers’
representatives, managers & subordinates).
 Effective decision maker within company rules (Able to make quick,
accurate and precise decisions).
 Ability to inspire, motivate and deliver continuous team
performance improvements.
 Strategic approach to operational services.
 In-depth knowledge of applicable laws and regulations related to
Business Operations.
 Organizational skills.
 Ability to interface professionally at all times with a variety of
different personalities.
 High level of work dedication.
 Comprehensive experience in people & team management.
 High work achievement with high concern for quality within strict
deadlines.
 Excellent experience in evaluation of computer system related to
health care & insurance services.
 Excellent experience in working with Microsoft Office & Oracle
Discoverer.
 High level of English language proficiency.
 High level of market orientation.
 Ability to put policy & procedures within my scope of
responsibility.
Personal Skills:
 Leadership skills.
 Communications & negotiations skills.
 Inspire teamwork.
 Presentation skills.
 Analytical Skills.
Thank You,