Job Description

Case Management, Client & Customer Services

• To provide advice, sound judgment and recommendation on case that surpasses the authority of a Executive. 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 Executive.
• 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

• Supervise, train, coach, and monitor Executive 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 report the status of the quality levels of Executive and their competency level and identify the areas requiring enhancement. This shall include proposal to Manager for Authority review or suspension.
• 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 actively participate in regular team meetings, provide feedback and support to Manager for day-to-day operational related matters/ issues.

System, Infrastructure Maintenance & Risk Management

• 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.
• Minimum 3 years of experience in Health Claim service.
• Experience in delivering client-focused solutions based on customer needs.
• Operational knowledge of how to manage customer service, claims and admin team processes and procedures is added advantage.