Executive, Health Claims

Job Scope / Position Summary

1. To provide preferred claims experience in accordance with the service standard and procedure guideline set.
2. Manage and settle legitimate claims.
3. Provide prompt response to internal and external customers at all times.
4. Participate and complete timely on the Projects assign.
5. Adhere to all claim operating guidelines and regulations.
6. All other and related job as stated in the job scope (which may be revised).

Main Responsibility

Claims Operations

• Registration, processing and adjudication of claims within turnaround time including monitoring and follow-up on unsettled/outstanding claims promptly.
• Handle claims assigned independently or with little supervision and to ensure Company's interests are fully protected by minimizing the claim costs.
• Investigation on suspicious claims and finalized the claims on a timely basis in accordance with the agreed policies, processes and operational procedures.
• Examine claims investigated by insurance adjusters, further investigating questionable claims to determine whether to authorize payments where necessary.
• To escalate grey area cases for medical bill vetting as per claims guidelines

Claims Costs

• Verify policy liability and alert relevant teams e.g. underwriters, technical review on any suspicious, fraudulent claims.
• Assess & ensure all the claims process for cashless and reimbursement are accurate.
• Manage claims settlement costs and related claims expenses and ensure compliance with internal controls.

Claims Reserving

• Reserves – ensures accuracy of reserve type use and adequacy of reserves for claims handled so that the Company’s liabilities are properly reported, and in compliance with Group & Internal reserving policies.
• File Reviews – ensure that claims assigned are reviewed regularly until closure and ensure fast disposal of valid claims.

Service Delivery & Customer Service

• Response to Customers – always provide prompt response to internal and external customers inclusive of enquiries from regulatory authorities.
• Provide good customer claim experience within service delivery benchmark.
• Contact customer and obtain/verify/ personal details contact number/email address/corresponding and update in system (NPS)
• Provide all kind of operational assistance & support for the Dept/Unit Lead

Projects, TPA Management & Reporting

• Assist in projects initiatives to improve efficiency and productivity of the department/company.
• Assist in TPA Management/Outsourcing/Own provider management where/when required.
• Proactively address and / or escalate any operational issues and complaint to superior.

Claims Governance

• Compliance – comply with the relevant requirements of the Insurance Act, 1996, Bank Negara Malaysia, PIAM, Company policies and procedures, Internal Audit requirements etc.

Qualification and Experience Requirement

• Degree in any recognized Institution and/or Diploma in Nursing
• AMII /ACII / DMII or equivalent insurance qualifications (is an advantage)
• Minimum of 2 years’ experience in similar role/capacity
• Knowledge in Health, PA & Travel Insurance related matters claim/policy
• Knowledge in TPA claim handling management
• Knowledge in Panel Hospital Network management is an advantage
• Good command of written and spoken English/Bahasa Malaysia with strong communication skill
• Possess good presentation skills. Result oriented, committed, team player, positive working attitude, good communication and interpersonal skill.