Executive, Claims (Shah Alam)

Job Purpose:
The Medical Claims Assessor is responsible for the accurate and timely assessment of medical claims, ensuring compliance with policy terms and conditions. This role requires the ability to evaluate claims documentation, handle inquiries, investigate potential fraud, and provide high-quality customer service while adhering to company protocols and deadlines.

Key Responsibilities:

Claims Assessment:

• Process and assess medical claims efficiently within the specified turnaround time, ensuring compliance with company policies, procedures, and insurance terms.
• Review and verify claims documentation for accuracy and completeness, including medical reports, invoices, and receipts.
• Collaborate with healthcare providers, clients, and internal teams to resolve any discrepancies in claims submissions.

Inquiries and Correspondence:

• Respond to inquiries related to medical claims, including feedback and complaints, promptly and professionally.
• Maintain clear and consistent communication with clients, ensuring they are kept informed of their claims' progress.

Document Management:

• Ensure that all requests for supporting documents and additional information required for claim assessments are followed up on and obtained in a timely manner.
• Maintain accurate records of claims, supporting documents, and communications in the claims management system.

Fraud Detection and Reporting:

• Investigate potential fraudulent claims, including irregularities in documentation or unusual patterns.
• Report any suspicious activity or claims irregularities to the appropriate supervisory personnel for further investigation.

Compliance and Accuracy:

• Ensure that claims assessments adhere to internal and external regulatory guidelines.
• Keep updated with the latest medical billing codes, insurance policies, and healthcare regulations.

Additional Duties:

• Perform ad hoc tasks and projects as assigned by supervisors or managers.
• Assist with process improvement initiatives related to claims management and customer service.

Essential Experience, Skills And Knowledge

• Candidate must possess at least a Diploma, Advanced/Higher/Graduate Diploma, Bachelor’s Degree, Professional Certificate in Medical Science/Nursing/Pharmacy/Insurance or any related field.
• Candidate with technical knowledge of medical claims or relevant working experience in Third Party Administration (TPA) / Insurance Industry will be an added advantage.
• Good command in English & Bahasa Malaysia, both speaking and writing.
• Able to work in fast paced environment, independent, customer focused and proactive working attitude with strong sense of responsibility.
• Must be computer literate with knowledge of office applications such as Word, Excel, etc.
• Flexible and willing to work extra hours as and when required.
• Possess own transport.

This position will be based in Bukit Jelutong, Shah Alam

Candidates are required to apply online and only shortlisted for interview will be contacted.