Medical Claims Specialist

Responsibilities

Overall responsibility in managing an Accident & Health Claims from the start through to settlement, making decisions on the extent and validity of a claim, and checking for any potentially fraudulent activity.

Support the Manager to develop and manage the medical provider network and medical services for Domestic and International customers including but not limited to Public and Private Hospitals, Doctors, Diagnostic, Dentists, and non-medical providers as required to support the assistance business.

Job Duties

  • Comply with Claims Operating Manual in claims reserving, strategy, and cost management.
  • Handle medical claims, inbound emails, and telephone enquiries from insured, medical providers, in line with the Claims Operating Manual.
  • Interview and communicate with claimants, police, witnesses, physicians, hospitals, and other necessary individuals to decide claim denial, settlement, or review.
  • Verifying medical claim and conduct a medical assessment for both reimbursement basis and cashless basis.
  • Examine medical treatment records, police reports, medical bills and others claim evidence to determine the medical coverage losses.
  • Liaising with hospitals with a view to eliminating unnecessary or irrelevant treatment, over-servicing, over-charging, and cost containment.
  • Providing a Letter of Guarantee (LOG) to the hospital or Denial Letter to claimant and Hospital.
  • Support the Manager to develop and manage the medical provider network and medical services for Domestic and International customers including but not limited to Public and Private Hospitals, Doctors, Diagnostic, Dentists, and non-medical providers as required to support the assistance business.
  • Recording and updating to ensure that all providers’ information is clearly recorded and updated in a timely and accurate format.
  • Co-ordinate with Medical Providers to ensure business continuity, efficiency, and service levels within the region through performance monitoring and training of Medical Providers in terms of delivery, quality, and efficiency in accordance with business requirements
  • Handle customer complaints, aiming to resolve situations to meet customers’ satisfaction.
  • Reporting and handling of concerns, and compliments from customers and third party with recommended solutions and areas of improvement.
  • Provide support in the implementation of strategies, projects and campaigns and assist with the co-ordination of any associated procedures in relation to new products, services, or campaigns
  • Perform other duties as assigned by Manager with fully supporting.

Requirements

  • Bachelor’s degree or higher.
  • At least two years of experience working in the medical field or nurse.
  • At least two years of experience as a medical claim specialist/examiner.
  • Good spoken and written communication skills (Good in English communication is an advantage)
  • Ability to resolve complex and complaints case
  • Travel upcountry
  • Excellent customer service and negotiation skills
  • Accuracy and attention to detail
  • Flexible to work as shift, holidays, weekends.
  • Good administrative and computer skills
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