Report to: Manager, Healthcare Claims
Location: Ho Chi Minh
Function: Customer & Information Technology | Department: Customer Office
Type: Individual Contributor
Position no.1: Claims Assessment_Direct Billing
THE OPPORTUNITY:
- Manage direct billing claims within the Turnaround Time (TAT) of 2 hours for final LOG, 30 minutes for outpatient cases, ensuring a 99% accuracy rate. Collaborate effectively with medical provider staff and proactively engage with medical providers to ensure customers have the best experience and expenses are controlled reasonably.
- Maintain a customer-centric approach throughout the claim process, achieving a customer satisfaction score of 90% or higher.
- Actively contribute at least three creative ideas per quarter to the team to enhance performance and achieve claim cost savings of 10%
ROLES AND RESPONSIBILITIES:
1. Direct Billing handling (60%)
- Thoroughly and promptly assess all direct billing cases, ensuring claims decisions within Claim Authority are based on valid grounds and fully comply with Claim guidelines, policies, and terms and conditions.
- Collaborate closely with hospital staff to ensure treatment expenses are necessary and appropriate, avoiding unnecessary abuse.
- Utilize classification software to accurately apply clinical codes in the system for each sub-benefit.
- Document patients health information, including medical history, examination and test results, and any treatments or procedures provided.
- Maintain the confidentiality of all patient records.
- Achieve claims SLA commitments to customers, distribution, and partners.
- Prepare proper documentation and, if possible, provide recommendations on cases referred to higher authority levels, the Claim Committee, or re-insurers for decisions.
- Proactively contribute good practices and ideas to the team to improve performance.
- Perform other responsibilities and duties as periodically assigned to support the companys business
2.Reimbursement claim handling (30%)
- As a claim assessor, to be responsible for processing reimbursement claim if assigned by manager.
- Training for newcomers about the healthcare claim practice, medical knowledge if any.
3. Customer inquiries (10%)
- Handle customer calls regarding claim information outside of regular working hours to ensure clear and accurate information is provided.
Position no.2: Claims Assessment_Reimbursement
THE OPPORTUNITY:
Manage and resolve claims in a fair, efficient, and empathetic manner to:
- Ensure that policyholders receive the appropriate compensation according to the terms and conditions of their insurance policies and ensure to bring the best claim experiences to customer.
- Minimize financial risks and protect companys financial state (A/E) by identifying potential fraud and implementing preventive measures
ROLES AND RESPONSIBILITIES:
1.Re-imbursement claim handling (80%)
- Managing the entire lifecycle of insurance claims from submission to resolution to ensure claims are processed accurately and timely.
- Evaluating claims based on policy coverage, medical necessity, and contractual agreements.
- Ensuring that claims processing adheres to regulatory requirements and claims procedure.
- Providing guideline, advice to team member or make final decision for the borderline cases.
- Process payment, ensure policy benefit and policy values to be calculated correctly and pay to the right Beneficiary.
- Communicate with customers/ providers to request additional documents.
- Work with POS team/ actuary/ UW for Policy value calculation.
- Prepare claims letter and to customers and keep agents updated about claims status/ results.
- Quality Assurance: Monitoring and auditing claim handling processes to maintain accuracy and efficiency including conducting audits, providing feedback to leader, and implementing improvements.
- Customer Service: Addressing inquiries and issues related to claims from healthcare providers, policyholders, and internal stakeholders.
- Provider Relationship: to ensure smooth operations between HC team and providers daily when dealing with direct billing.
2.Direct Billing claim handling (20%)
- Support or handle cashless claim in case of high volume of claims following manager directions.
- Back up assessor, who is responsible for direct billing hotline, in case of her/his absence.
JOB REQUIREMENTS:
- Education University Graduate.
- Experience At least 3 years of experience in medical claim at an insurance company
- Certifications/licenses LOMA certificate
- Good in communication and interpersonal skill, decision-making skill, management skill and planning skill.
- Medical background is preferred.
- Customer Service Mindset
- Good in English speaking and writing
