To review claims document examinations and provide recommendation on claim eligibility within Authority.
To provide advice, sound judgment and recommendation on case that surpasses the authority of a Senior Officer. Provide advice with appropriate referrals/ escalations as and when needed.
To authorize, deny and determine extent of insurer's liability on case of discharge that surpasses the authority of a Senior Officer.
To ensure claims recommendations and decisions are complied with legal requirements, industry regulations, company policies and professional codes. To report to Manager of any claims fraudulent.
To assist manager on establish strategies to manage the cost of health insurance. Ensure cost containment is practiced when adjudicating claims.
Performing internal audit on claim assessment accuracy by recording errors notice in claim audit sheet.
Prepare and analyse audit results, provide improvement suggestion to manager.
Ensure no delay in the provision of services and cases to be closed in a timely manner within the agreed SLA.
Execute SOPs, best practices, ISO policies and ensure compliance with policies. This shall include compliance of legislative requirement such as data protection and medical confidentiality.
Ensure internal customer requests / inquiries for retrieval of claim documents are well attended on timely manner.
Respond to clients' enquiries via phone calls, e-mails and faxes within agreed client SLA, offering appropriate solutions and information.
To cross- expose to any other areas/ team intra or inter department, to take up any other tasks as deemed fit or as assigned by the reporting supervisor when needed.
Quality Assurance, Training & Staff Management
Assist Associate Manager to supervise, train, coach and monitor senior officers and officers on job responsibilities.
Conduct Quality Assurance/ Control on regular/ routine basis ensuring efficiency, effectiveness and performance are always achieved and maintained in accordance to SLA set- forth by the clients.
To assist Manager to conduct audits of ISO policy and compliance of standards.
To assist Manager to solve specific training problems, either on a one- to- one basis or in groups.
To report faulty to manager and work closely with IT for the maintenance and upkeep of systems ensuring day- to- day operation runs smoothly without interruption.
To be responsible for the readiness, reliability and stability of systems and systems related operating facilities.
To involve in risk management, which includes analysing, identifying, evaluating and estimating the risks which may affect the continuity of business.
To work closely with Manager to execute and initiate Business Continuity Plans (BCP).
Qualifications
Technical/ Functional Knowledge, Skills and Abilities
Proficient in Microsoft applications and Outlook
Good spoken and written communication skills are necessary for daily contact with customers, providers and inter-offices
Proficient in both spoken and written English, Bahasa Malaysia & Chinese (Cantonese/Mandarin)
Education, Professional Qualifications and Experience
Degree in Science/Nursing/ Medical bioscience or related field.
Knowledge in health insurance product in added advantage
Experience in Health Claim service is advantage.
Beware of fraud agents! do not pay money to get a job
MNCJobz.com will not be responsible for any payment made to a third-party. All Terms of Use are applicable.