Job Description

FIND YOUR \'BETTER\' AT AIA If you believe in better, we\'d love to hear from you. About the Role The position is responsible to: . Conduct surgical and medical history check on claims . Identify breach of duty of good faith and non-disclosure . Ensure risk are priced correctly and non-disclosed conditions excluded accurately and modified . Perform prospective, concurrent and retrospective review of hospitalization . Ensure cost containment measures are carried out without compromising on the care quality and service standards. Roles and Responsibilities: Conduct extensive search using via internet on clinical/hospital network based on the insured residential/office address. Call clinics/hospital listed from the search and obtain as much hits as possible via call/case. Record new investigation request daily. Conduct medical history check within the agreed turn-around time (TAT). Record the findings in the shared drive report at end of day. Follow up on pending cases or at times help to collect medical reports, documents authentication, etc. Process reimbursement claims in compliance to Company\'s requirements and guidelines. Issue APS deferment and pending requirement letter for new incoming case. Review/probe the medical history of an insured to establish whether any elements of material non-disclosure, which occurred prior to policy inception or reinstatement as per hints written in the medical report through APS questionnaire, geographical checks with medical providers and verification with other insurers. Liaise with underwriting to obtain evaluation whether non-disclosure is material to the policy declaration and to impose premium loading/ exclusion/ voidance of policy. Review underwriting decision based on evidence and notify Policy Servicing Team (POS) to issue counter offer letter or policy voidance instruction. Issue closing letters accurately and correctly within targeted TAT and with authority assigned. Achieve TAT, target productivity benchmark, achieve CFA scores and Claims adjudication rate as required. Ensure error rate / QA score in claims is below target with Zero Write offs and complaints. Accomplish Implemented Process improvement initiatives resulting in improved QA and SLA. Assist in closing of pending cases 60 days. Assist in the assignment and monitoring of all documents received in their respective team\'s queues. Assist other departments in ensuring enough headcount as scheduled on the shift rotation on a monthly basis to cater for backlog and manage team shrinkage. Ensure huddles and communications are carried out as per the agreed frequency. Ensure coaching and engagement activities are carried out for performance improvement and cost containment. Ensure error rate in investigations team is less than the target. Maintain close rapport with Medical Providers and other stakeholders. Process and approve assigned Inpatient Claims/Outpatient claims/PRP claims including overseas bills and Hospital income claims within the stipulated TAT and authority limit. Ensure assigned PRP investigation cases are reviewed accurately and completed within the stipulated TAT and refer to in-house Dr for opinion for post underwriting cases requiring special handling. Review pending cases and ensure cases exceeding 90 days are closed and to send out final reminder. Process claims according to the department\'s practice and guidelines. Clear HAP on daily basis and staff HAP (if any junior staff assigned). Execute plan, projects, special assignments and task force assigned by Managers. Execute ad-hoc assignments and task assigned by Team Leader. Attend to e-mail enquiries and phone calls from agents on claim status. Prepare settlement tables for each overseas claim. Make recommendation to Managers for claims exceeding approval authority, with updated EWS on the total quantum, claims details, diagnosis, procedure and the non-payable items listed accurately in EWS. Ensure all assessed claims to be input with benefit calculator, including for investigations and deferment claims. Ensure all E-payment, manual payment and journal correctly input to meet the department goal. Ensure claims are not pending unnecessarily and with no follow up action within 3 working days. Back up Takaful team as and when requested. Liaise with adjusters, legal advisor, principal medical officer, medical institutions, relevant government bodies and other insurers to determine validity and liability of the Company. Minimum Job Requirements: Education: Bachelor\'s Degree in medicine, biomedical, nursing, biotechnology, biology, physiotherapy, biochemistry, nursing or any other related field. Years of Experience: Minimum 5-8 years of relevant experience. Technical Skills: guarantee letter issuance, healthcare delivery systems, hospital management, billing system. Industry: Health Insurance, Third-Party Administrator, Hospitals. Language: English and Bahasa Malaysia Good communication and interpersonal skill. Good team player. Able to work with minimum supervision. Able to work on shift hours. Able to work under pressure

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