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Senior Manager, Medical Advisory, Case & Fraud Management

Salary undisclosed
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FIND YOUR 'BETTER' AT AIA

We don’t simply believe in being ‘The Best’. We believe in better - because there’s no limit to how far ‘better’ can take us.

We believe in empowering every one of our people to find their 'better' - in the work they do, the career they build, the life they live and the difference they make. So that together we can support even more people - including our own - to live Healthier, Longer, Better Lives.

If you believe in better, we’d love to hear from you.

About the Role

Position Objective :

• To lead, coach, supervise and adjudicate work flow and follow up on medical audit cases and the case management team/Top up GL/Additional doctor request and GL appeals.
• Review and coordinate cases that require the involvement and escalation to providers and internal stakeholders.
• To provide medical advisory within and beyond AHS
• To support operations of the AHS
• To assist in Fraud, Waste and Abuse initiatives.
• To actively participate in all initiatives related to cost savings & containment exercise
• To align claims practices across various units in AIA
• Medical Training for AIA Health Services and stakeholders
• Active lead in regulator collaborations- MOH/MTA/LIAM
• To collaborate with all AIA units in digitalization related to medical claims

Roles and Responsibilities:

1. Fraud, Waste & Abuse

  • Oversee and improve upon current methodology for FWA detection, resolution and prevention while driving the TDA program of work – Mapping of codes /Guides translation into AI engines and etc
  • Managing audits within and beyond AIA - Micare& doctors trendings under FWA
  • In charge of analysis on emerging patterns and trends in medical Fraud, Waste and Abuse (FWA) practices
  • Trends doctor’s charges and reviews charging behaviour to establish over utilization – which is supplementary to the provider conversation and trending reports.
  • Collation of reasonable and customary charges within the industry to ensure that charges are within benchmark.
  • Facilitate and implement controls on FWA prevention and minimization of billing wastages.
  • Ensuring recoveries are given within the agreed TAT
  • Close collaboration with the Field investigators to ensure Fraud outcomes are met
  • Active conversation with providers to address Fraud and Waste elements while ensuring strong outcomes are met with the providers

2. Medical advisory lead within and beyond AHS

  • Overseeing medical advisories from AHS and all stakeholders are replied within TAT
  • To review appeals on claims decline with concrete and robust medical literature to support the decision- Within AHS and all complaints related to OFS and BNM
  • Provide medical insights to various divisions within AIA such as Health Claims Management, Network Management and Healthcare Strategy, Corporate Solutions, and Customer Experience.

3.Strengthening cost containment measures directly related to Operations.

  • Supplementary GL issuance team, LOS monitoring
  • To ensure SLA and TAT is adhered
  • Attrition and people management
  • Reporting on Cost savings

4. Case Management and complex Case reviews

  • Case Management -adhering to the PHFSA schedule& binding of R&C guides
  • Attrition and people management
  • Reporting on Cost savings
  • Audits related to Hospital bills and provider Ops issues

5.Strengthening clinical and technical guidelines and assessment.

Alignment of cashless and ‘pay and file’ & investigation claim practices across AIA and strengthening of claims decisions & clinical guidelines.

  • Building and improving guidelines that will enable better decision making and Cost savings outcomes meeting stipulated goals set for the year.

6. Medical training lead

To understand the training needs of AHS and ensure adequate training is provided to on both Cashless and reimbursement claims across Individual benefits & Employee benefits portfolios, ensure that they are competent to deliver the services in accordance with the standards set.

  • Ensuring all medical trainings are conducted with solid outcomes within and beyond AHS
  • Assisting trainers beyond AHS- customer care, contact center and CSD to strengthen their medical knowledge

7. Collaborations - Within and beyond AIA

  • Ensuring Ops is abreast with latest medical advancements - Trainings and Guidelines
  • Agency level -Training & complaints Management
  • Frontliners -Branch/Contact Centre & Customer corresponding - Training on important Claims materials
  • Product and Marketing - Selection of GIO criteria /feedback on product design
  • Providers- Active discussion with doctors and hospital management in the FWA space
  • Regulator -Supporting MTA, JTC, LIAM, PIAM, Shariah Committee including presentation, meeting, and surveys.

8.Investigation for Minor Claims

  • Overseeing the investigation process under minor Claims
  • Close collaboration with New Business unit- Under writing for Investigation outcome management
  • Enhancing and improving processes in place for better customer experience

9. Repatriation & evacuation lead

  • Managing Advisories related to benefits and medical conditions
  • Ensuring payment process is within Stipulated SLA

10. PMCM lead

  • Ensuring sustainable Utilization
  • Ensuring reporting and Queries meet the Stipulate SLA

11. Others

  • Provide guidance and leadership in resolving issues and that affect the member experience.
  • Approving claims within his/her authority limit.
  • Review and approval of people movement, talent identification and development activities for the functional areas.
  • Provide guidance to direct reports in the areas of continuous improvement.
  • Work across functions with peers in other department/divisions to ensure collaboration and achievements for shared goals.
  • Interact with senior management for reporting, escalations, complaint handling, issue resolution and regulatory matters.
  • Facilitating goal-level creation for the broader function and work with managers to ensure the goals are cascaded to all team member.
  • Actively monitoring and support new product launching and provide operation support – system and resources

Minimum job Requirements:

  • Preferably Medical Doctor (MBBS / MD)
  • Strong business acumen with strategic thinking – ability to prognosticate factors that drive healthcare costs.
  • Good knowledge of current healthcare delivery systems and hospital billing system.
  • Good stakeholder engagement skills (Providers / internal teams)
  • Working experience in managed care organizations and insurance with familiarity with claims platforms (G400/CRM/MCS/LA)
  • Proficiency in Insurance product knowledge and experience
  • Dynamic with enthusiasm to lead with passion to provide seamless customer experience while ensuring compliance to insurance regulations.
  • Experience in Analysis, Fraud detection is an added advantage.

Build a career with us as we help our customers and the community live Healthier, Longer, Better Lives.

You must provide all requested information, including Personal Data, to be considered for this career opportunity. Failure to provide such information may influence the processing and outcome of your application. You are responsible for ensuring that the information you submit is accurate and up-to-date.