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Job Description

The incumbent need to follow the Operating Manual as guidance to standard operating process in administering all types of claims, including both reimbursement and direct billing cases.
He/She is responsible for processing daily claims volume within the expected quality standards, standard processing time SLA, and overall turnaround time, including cases involving second-level review for adjudication and approval.
The regular assessment process may subject to change as when there is system improvement arise from automation which the assessor is required to constantly follow through the change and update diligently to ensure the assessment comment/decision is being captured and escalated.
The incumbent is required to update claims decisions, assessment comments, and case status accurately in the relevant systems, including RCS, TPA portal, or other systems in use. In situation the automation is not supporting, the incumbent will require to support the automation manager to rectify reason of the productivity not capture and continue to produce manual record.
The incumbent is responsible for rectifying any incorrect processing or claim decision in a timely manner, with proper justification and escalation in accordance with internal procedures.
All complex or investigation-related cases, including cases involving out-of-system communication, must be properly documented, with relevant information uploaded into the required systems and escalated for approval where applicable.
When claims assessor involved in investigation cases which may have out of system communications, claims assessor need to ensure all information are to upload in the systems in use.
For cases requiring additional clarification, especially those with potential complaint exposure, the incumbent may be required to communicate with customers, hospitals, or providers professionally and in accordance with company guidance.
The incumbent is expected to maintain productivity and quality standards, provide explanation on performance gaps when required, and support continuous process compliance in line with internal risk and quality requirements.
He/She is expected to participate in training, development activities, and any other duties or projects assigned by management from time to time.
Claims adjudicator is required to perform audit on monthly claims cases. Interchangeable (Direct billing versus reimbursement cases in Quality Assurance) in response to the evaluation to ensure quality of assessment achieve.
Specific focus to focus on decision, process compliance on all document, calculation of payment according to product's table of benefits, diagnosis with appropriate treatment and LOS in accordance with good standard of medical necessary practice with all FWA include unnecessary LOS to be recorded and communicated to providers/TPA, to ensure the risk control is within the HC quality assurance framework.
He/She will need to prepare case study on out of force policy coverage or exgratia exceptional handling proposal.
Continuously attend / involve with training for personal and career development.
Undertake projects / other work and duties allocated by management as and when required.

Job Accountability /

To support HealthCare Manager to perform daily adjudication of healthcare claims for both reimbursement and direct billing cases in accordance with the Operating Manual, service level standards, and quality requirements review complex or referred cases, support quality assurance and audit activities, ensure accurate claims decisions and system updates, and assess medical charges, treatment appropriateness, and payable benefits in line with policy provisions, medical necessity, and risk control requirements.

Job Requirements / Yêu cu

a. Qualification

Degree in Biomedical Science, Allied Health, Nursing or Biological Sciences and etc.

b. Experience

Preferably experience in healthcare and/or claims, i.e. customer Service, HealthCare claims department or Hospital environment for at least 2-5 years.

c. Knowledge, Skills & Attributes

Healthcare & Audit of Insurance/hospital related skills

Good customer service background on claims or healthcare claims

Good knowledge of life insurance claims processing

Computer literate and familiar with MS Excel, MS Word & MS Powerpoint

Innovative/Creative

Self-assured and results oriented

Prudential is an equal opportunity employer. We provide equality of opportunity of benefits for all who apply and who perform work for our organisation irrespective of sex, race, age, ethnic origin, educational, social and cultural background, marital status, pregnancy and maternity, religion or belief, disability or part-time / fixed-term work, or any other status protected by applicable law. We encourage the same standards from our recruitment and third-party suppliers taking into account the context of grade, job and location. We also allow for reasonable adjustments to support people with individual physical or mental health requirements.

Claim Assessment Senior Specialist (Chuyên viên C?p cao D?ch v? Th?m ??nh B?i th??ng)