Executive, Accident & Health Claims

Job summary:

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

Key responsibilities:

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 eg 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 require ments etc.

Requirements:

• Degree in any recognized Institution and/or Diploma in Nursing
• AMII /ACII / DMII or equivalent insurance qualifications (is an advantage)
• Fresh Graduate Or Minimum of 2 years’ experience in and /or 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

Job Type: Contract
Contract length: 12 months

Pay: Up to RM2,200.00 per month

Schedule:

• Monday to Friday

Work Location: In person