Senior Executive, Health Claims - Dynamic Team

Job responsibilities

1. Claims Operations 

• Registration, processing and adjudication of claims within turnaround time including monitoring and follow-up on unsettled 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
• To guide Junior on daily operation duties including review and advise Junior for complex cases including checking & approve claims assessment above Junior’s authority.

 2.  Claims Costs

• Verify policy liability and alert relevant teams eg underwriters, technical review on any suspicious, fraudulent claims.
• Assess & ensure all the claims process by Third Party Administrator are accurate.
• Manage claims settlement costs and related claims expenses and ensure compliance with internal controls.

  3.  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 reserving policies.
• File Reviews – ensure that claims assigned are reviewed regularly until closure and ensure fast disposal of valid claims. 

  4.  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

 5.  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 and ensuring they are performing according to SLA.
• Proactively address and / or escalate any operational issues and complaints to superior.

  6.  Governance

• Compliance – comply with the relevant requirements of the Financial Services Act 2013, Bank Negara Malaysia, PIAM, Company policies and procedures, Internal Audit requirements and other related governing policies etc.

Job requirements

• Candidates must possess Degree in any and/or Diploma in Nursing or AMII/ACII/DMII or equivalent insurance qualification.
• Candidates must at least have a minimum of 3 – 5 years’ experience in and/or similar role/capacity.
• Candidates must be proficient in English, have good presentation & negotiation skills and IT literate.
• Candidates must have mature personality, able to work independently, self-motivated, a team player and able to handle high volume of work with speed and accuracy.