Responsible to provide professional medical expertise and advice in relation to claims, medical / healthcare portfolio management and to sustain operational effectiveness, cost efficiency for Group and Individual Businesses.
Responsibilities
TPA / Medical Claims Management
- Provide second opinions on complex medical cases to validate or contest the decisions made by TPAs.
- Perform regular quarterly claims audits on all TPA offices and prepare materials for regulatory audits.
- Review and evaluate medical claims submitted by TPAs to ensure they meet clinical guidelines and Takaful's terms.
- Resolve issues by reviewing or requesting additional information from outside sources and Third Party Administrator when necessary.
- Be on site for investigation (if any) in case of performing a random check outside the office or on the delivery of the hospital network.
- Coordinate with the Networking Department to work with providers on appropriate claim submission and payment resolution issues, and work closely with other departments to assure smooth coordination of efforts and resources.
Claims Assessment / Medical Claims Training
- To lead cost containment initiatives and develop utilization management strategies by applying data analytics, predictive models and industry trends.
- To develop operational improvement strategies related to medical aspects by applying data analytics, predictive models, and industry trends.
- To analyze claims and other relevant information to derive with data driven recommendation for business improvement and growth and support assessment to sustain the profitability of the medical schemes and other products offered by the Company.
- To maintain a high level of clinical expertise and continuously seek opportunities to expand takaful knowledgebase and advance clinical knowledge / skills for Operations team.
- To provide medical advisory and authorizer on analyze claim related cases and support on service provider management.
- To support and assist any projects or ad-hoc task as assigned or identified from time to time at departmental and company level.
Qualifications
- Degree in Nursing, Insurance, Internal Medicine or any related filed in Medical Sciences.
- Minimum 2 years working experience (clinical) in healthcare or insurance industry.
- Possess a valid Annual Practicing License would be an added advantage.
- Able to liaise effectively with representative from Insurance companies and corporate clients as well as treating doctors from panel hospitals.
- Good spoken and written communication skills in English.
- Possess strong interpersonal, leadership and analytical skills to enable further success in this role which requires to work with multiple stakeholders of different disciplinary teams.
- Demonstrate strong business acumen and being resourceful to drive value added activities for the company.
