Job Scope / Position 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.
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 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 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 2 years relevant experience in similar role/capacity; fresh graduates are encouraged to apply
- 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
- Result oriented, committed, team player, positive working attitude, good communication and interpersonal skill
- Ability to adapt and learn fast, diligent, trustworthy and have strong initiative to learn
