Assistant Director, Health Ecosystem

Prudential’s purpose is to be partners for every life and protectors for every future. Our purpose encourages everything we do by creating a culture in which diversity is celebrated and inclusion assured, for our people, customers, and partners. We provide a platform for our people to do their best work and make an impact to the business, and we support our people’s career ambitions. We pledge to make Prudential a place where you can Connect, Grow, and Succeed.

The incumbent is responsible to lead the Medical Claims Fraud, Waste and Abuse (FWA) detection and Claims Avoidance Rate in Prudential to ensuring long-term sustainability of portfolio. With strong knowledge in medical and Insurance processes, the incumbent will lead & strategize to maintain and strengthen Health Ecosystem Department’s capability in eliminate leakages.

The incumbent is also responsible for overseeing the development and management of the healthcare provider network for PruBSN Takaful. This includes negotiating contracts with healthcare providers, ensuring network adequacy and maintaining positive relationships with providers to ensure high-quality care for members.

Drive exceptional customer experience by providing fast & quality decision & enhancing skill set for complex medical areas & creating best in class claims service & framework Initiate exceptional customer experience at Hospitals & panel clinics along with providing support for operational efficiency & long-term portfolio sustainability. Create seamless customer experience at the point of delivering customer promise – claims by creating high degree of Automation. Enable new health related offerings via Pulse, in line with latest trends and medical advancements. Support long term sustainability of Insurance portfolio & creating efficiency by creating insights through Data analytics (Internal & External Data) by utilizing AI & analytics to create opportunities for growth & improvement.

Responsible for fostering relationships with panel hospitals through regular visits, performance reviews, and strategic initiatives with hospital management. It is also crucial that the team drives Prudential's goals and vision to the panel hospitals, including promoting the PruWay. This includes ensuring that our customer is our compass, pursuing our entrepreneurial spirit, succeeding together, respecting, and caring for one another, and delivering on our commitments. Additionally, they ensure that hospital services and charges adhere to the Private Healthcare Act.

Key Accountabilities

• Performing the role as a lead in managing staff and to ensure task assigned to team member complete within given time to meet expectations on operational processes.
• To lead and coordinating the team member to achieve the company’s goal in providing support and guidance to Claims Department via assessor knowledge, guidelines, systems, technology, etc.
• To support and provide analysis to internal stake holder in monitoring effectiveness and detect gaps to develop new initiatives and measures to achieve the goal.
• Manage & provide claims training for claims assessors to ensure skills are continuously improved through external trainings or customized technical training program.
• Provide and support claims training to other departments or business partners.
• Manage and perform claims review on claims assessor’ cases as part of claims authority upgrade process.
• Manage and report on claims/compliance audits to ensure quality assessment and compliance is achieved and identify any improvement areas.
• Perform regular review of underwriting guidelines to ensure that it is relevant, competitive and to drive operational efficiency while maintaining good risk management and long-term sustainability of Portfolio.
• To work closely with other departments and vendors in delivering robust Claims process flow & develop and maintain rules in the claims system for STP and identify opportunities that provide operational efficiency, support business growth and seamless customer experience.
• Leverage on internal & external data to understand current state, trend and opportunities in improvement/growth area.
• Support improvement in SLA and minimizing penders through identifying improvement opportunities, automation, streamlining processes & guidelines.
• Support improvement in onboarding NPS through various initiatives, manage and monitor the team performance in meeting departmental service expectations and deliver excellent service quality to customer.
• Participate in Roadshows, Quality leaders meeting and focus group dialog to gain insight and provide education on Medical Claims and FWA.
• Developing and implementing strategies to build and maintain a high-quality provider network and TPAs where needed.
• Negotiating contracts with healthcare providers, including fee schedules and performance metrics.
• Monitoring network performance and provider satisfaction and implementing improvements as needed.
• Identify global best practices in provider management for adoption, as appropriate in markets.
• Collaborating with internal teams, such as operations, finance, and quality management to ensure network alignment with organizational goals.
• Analyzing data and trends to identify opportunities for network expansion and optimization & perform analytics on network providers to assess performance metrics and provide insights for LBUs.
• Ensuring compliance with regulatory requirements and accreditation standards related to provider network management.
• Develop framework to evaluate medical service providers and their value delivery, integration and funding model.
• Develop framework/guidelines & support LBUs in conducting agreed fee/discount negotiations with providers on price, volume and outcome.
• Define standards for partnership identification, support LBUs in assessing partners’ ability to deliver appeal and sustainability by conducting clinical due diligence + Define standards and support LBUs in enhancing capabilities in pharmaceutical benefits management.
• Closely works with Claims team for feedback to providers and vice-versa to claims team on findings from analytics on provider performance.
  
  
  

Qualifications

• Possess a degree in the related science field such as Biomedical Sciences, Biology, Science etc.
• Good knowledge of insurance operations processes and insurance product with at least 15 years of life and health claims experience.
  
  
  

Knowledge / Experience

• Proficient in Microsoft Application e.g. Visio, Excel, Power Point and Word.
• Articulate and proficient in written and spoken English.
• Strong analytical skills with the ability to collect, organize and analyze large and complex sets of data/information.
• Able to multi-task and manage changing priorities effectively.
• Able to work independently and in a team, is self-motivated, resourceful, and reliable.
• Proactive, result-oriented and takes pride in their quality of work.
• Is meticulous and has a keen eye for details.
• Proficient in Microsoft Application e.g. Visio, Excel, Power Point and Word.
• Articulate and proficient in written and spoken English.
• Strong analytical skills with the ability to collect, organize and analyze large and complex sets of data/information.
• Able to multi-task and manage changing priorities effectively.
• Able to work independently and in a team, is self-motivated, resourceful, and reliable.
• Proactive, result-oriented and takes pride in their quality of work.
• Is meticulous and has a keen eye for details.
  
  
  

Prudential is an equal opportunity employer. We provide equality of opportunity of benefits for all who apply and who perform work for our organisation irrespective of sex, race, age, ethnic origin, educational, social and cultural background, marital status, pregnancy and maternity, religion or belief, disability or part-time / fixed-term work, or any other status protected by applicable law. We encourage the same standards from our recruitment and third-party suppliers taking into account the context of grade, job and location. We also allow for reasonable adjustments to support people with individual physical or mental health requirements.

Prudential’s purpose is to be partners for every life and protectors for every future. Our purpose encourages everything we do by creating a culture in which diversity is celebrated and inclusion assured, for our people, customers, and partners. We provide a platform for our people to do their best work and make an impact to the business, and we support our people’s career ambitions. We pledge to make Prudential a place where you can Connect, Grow, and Succeed.

The incumbent is responsible to lead the Medical Claims Fraud, Waste and Abuse (FWA) detection and Claims Avoidance Rate in Prudential to ensuring long-term sustainability of portfolio. With strong knowledge in medical and Insurance processes, the incumbent will lead & strategize to maintain and strengthen Health Ecosystem Department’s capability in eliminate leakages.

The incumbent is also responsible for overseeing the development and management of the healthcare provider network for PruBSN Takaful. This includes negotiating contracts with healthcare providers, ensuring network adequacy and maintaining positive relationships with providers to ensure high-quality care for members.

Drive exceptional customer experience by providing fast & quality decision & enhancing skill set for complex medical areas & creating best in class claims service & framework Initiate exceptional customer experience at Hospitals & panel clinics along with providing support for operational efficiency & long-term portfolio sustainability. Create seamless customer experience at the point of delivering customer promise – claims by creating high degree of Automation. Enable new health related offerings via Pulse, in line with latest trends and medical advancements. Support long term sustainability of Insurance portfolio & creating efficiency by creating insights through Data analytics (Internal & External Data) by utilizing AI & analytics to create opportunities for growth & improvement.

Responsible for fostering relationships with panel hospitals through regular visits, performance reviews, and strategic initiatives with hospital management. It is also crucial that the team drives Prudential's goals and vision to the panel hospitals, including promoting the PruWay. This includes ensuring that our customer is our compass, pursuing our entrepreneurial spirit, succeeding together, respecting, and caring for one another, and delivering on our commitments. Additionally, they ensure that hospital services and charges adhere to the Private Healthcare Act.

Key Accountabilities

• Performing the role as a lead in managing staff and to ensure task assigned to team member complete within given time to meet expectations on operational processes.
• To lead and coordinating the team member to achieve the company’s goal in providing support and guidance to Claims Department via assessor knowledge, guidelines, systems, technology, etc.
• To support and provide analysis to internal stake holder in monitoring effectiveness and detect gaps to develop new initiatives and measures to achieve the goal.
• Manage & provide claims training for claims assessors to ensure skills are continuously improved through external trainings or customized technical training program.
• Provide and support claims training to other departments or business partners.
• Manage and perform claims review on claims assessor’ cases as part of claims authority upgrade process.
• Manage and report on claims/compliance audits to ensure quality assessment and compliance is achieved and identify any improvement areas.
• Perform regular review of underwriting guidelines to ensure that it is relevant, competitive and to drive operational efficiency while maintaining good risk management and long-term sustainability of Portfolio.
• To work closely with other departments and vendors in delivering robust Claims process flow & develop and maintain rules in the claims system for STP and identify opportunities that provide operational efficiency, support business growth and seamless customer experience.
• Leverage on internal & external data to understand current state, trend and opportunities in improvement/growth area.
• Support improvement in SLA and minimizing penders through identifying improvement opportunities, automation, streamlining processes & guidelines.
• Support improvement in onboarding NPS through various initiatives, manage and monitor the team performance in meeting departmental service expectations and deliver excellent service quality to customer.
• Participate in Roadshows, Quality leaders meeting and focus group dialog to gain insight and provide education on Medical Claims and FWA.
• Developing and implementing strategies to build and maintain a high-quality provider network and TPAs where needed.
• Negotiating contracts with healthcare providers, including fee schedules and performance metrics.
• Monitoring network performance and provider satisfaction and implementing improvements as needed.
• Identify global best practices in provider management for adoption, as appropriate in markets.
• Collaborating with internal teams, such as operations, finance, and quality management to ensure network alignment with organizational goals.
• Analyzing data and trends to identify opportunities for network expansion and optimization & perform analytics on network providers to assess performance metrics and provide insights for LBUs.
• Ensuring compliance with regulatory requirements and accreditation standards related to provider network management.
• Develop framework to evaluate medical service providers and their value delivery, integration and funding model.
• Develop framework/guidelines & support LBUs in conducting agreed fee/discount negotiations with providers on price, volume and outcome.
• Define standards for partnership identification, support LBUs in assessing partners’ ability to deliver appeal and sustainability by conducting clinical due diligence + Define standards and support LBUs in enhancing capabilities in pharmaceutical benefits management.
• Closely works with Claims team for feedback to providers and vice-versa to claims team on findings from analytics on provider performance.
  
  
  

Qualifications

• Possess a degree in the related science field such as Biomedical Sciences, Biology, Science etc.
• Good knowledge of insurance operations processes and insurance product with at least 15 years of life and health claims experience.
  
  
  

Knowledge / Experience

• Proficient in Microsoft Application e.g. Visio, Excel, Power Point and Word.
• Articulate and proficient in written and spoken English.
• Strong analytical skills with the ability to collect, organize and analyze large and complex sets of data/information.
• Able to multi-task and manage changing priorities effectively.
• Able to work independently and in a team, is self-motivated, resourceful, and reliable.
• Proactive, result-oriented and takes pride in their quality of work.
• Is meticulous and has a keen eye for details.
• Proficient in Microsoft Application e.g. Visio, Excel, Power Point and Word.
• Articulate and proficient in written and spoken English.
• Strong analytical skills with the ability to collect, organize and analyze large and complex sets of data/information.
• Able to multi-task and manage changing priorities effectively.
• Able to work independently and in a team, is self-motivated, resourceful, and reliable.
• Proactive, result-oriented and takes pride in their quality of work.
• Is meticulous and has a keen eye for details.
  
  
  

Prudential is an equal opportunity employer. We provide equality of opportunity of benefits for all who apply and who perform work for our organisation irrespective of sex, race, age, ethnic origin, educational, social and cultural background, marital status, pregnancy and maternity, religion or belief, disability or part-time / fixed-term work, or any other status protected by applicable law. We encourage the same standards from our recruitment and third-party suppliers taking into account the context of grade, job and location. We also allow for reasonable adjustments to support people with individual physical or mental health requirements.