Job Description

Overview

The Utilization Management (UM) & Claims Manager is responsible for overseeing the day-to-day operations of both the utilization management and medical claims review processes. This role ensures that all inpatient, outpatient, emergency, elective, and dental procedures are reviewed based on medical necessity, appropriateness, benefit coverage, and member eligibility. The manager will also oversee claims processing workflows, ensuring accuracy, compliance with service-level standards, and alignment with clinical and contractual requirements.

The role involves team management, process optimization, clinical review collaboration, and strong coordination with customer service, provider relations, finance, and technology teams.

Key Responsibilities:

Utilization Management

Oversee prior authorization and concurrent reviews for inpatient, outpatient, emergency, elective, and dental treatments based on medical necessity and benefit eligibility. Conduct medical reviews and ensure all decisions comply with international clinical guidelines and client-specific protocols. Coordinate inpatient case management, discharge planning, and continuity of care with hospitals and providers. Work closely with the Medical Director and UM leads to ensure clinical appropriateness and alignment with company policies. Ensure turnaround times and service level standards are met for all authorizations and medical reviews. Issue guarantee letters for approved inpatient admissions and finalize payment responsibilities prior to discharge. Monitor utilization patterns and contribute insights to product development and cost-containment strategies.

Claims Management

Oversee the accurate processing and adjudication of health and dental claims. Ensure all claims are evaluated based on medical necessity, plan benefits, member eligibility, pre-existing conditions, exclusions, and policy rules. Validate proper application of provider fee schedules, discounts, and authorization requirements. Collaborate with the Medical Review team to resolve complex or questionable claims. Manage claims documentation workflows, including claim numbering, scanning, data entry, Prepare and issue Explanation of Benefits (EOBs) to members and coordinate any follow-ups for incomplete or denied claims. Conduct fraud and abuse detection activities in collaboration with compliance and medical teams. Liaise with finance for timely liquidation of processed claims.

Team and Process Management

Lead, coach, and support a team of UM reviewers, claims processors, and encoders. Monitor and evaluate individual and team performance against KPIs and SLAs. Ensure continuous process improvement and contribute to automation or digital optimization initiatives. Maintain detailed reports, dashboards, and logs related to claims and utilization management functions. Provide timely reports to leadership on claims turnaround, utilization trends, and issue escalations.

Cross-Functional Support

Support customer service teams with benefit clarifications and claims-related inquiries. Coordinate with provider relations on clinical guideline adherence and claims education. Participate in client calls or audits as needed to clarify claims and UM decisions. Recommend enhancements to workflows, systems, and policies based on operational insights.

Educational Background

Bachelor's degree in

Nursing

,

Allied Health

, or

Healthcare Administration

Active

professional license

(e.g., RN, RMT, PT) as required by role Additional certifications in

Utilization Review

,

Case Management

, or

Medical Coding

(e.g., CPC, CCS) are preferred
Job Type: Full-time

Pay: From RM8,500.00 per month

Benefits:

Dental insurance Flexible schedule Health insurance Maternity leave Parental leave
Education:

Bachelor's (Required)
License/Certification:

Registered Nurse License (Required) SCI/CGI Certification (BCP, PGI, HI) (Required)
Work Location: In person