Healthcare Network Operations Senior Specialist (Chuyên viên Cấp cao Nghiệp vụ Hệ thống CSYT)

Prudential's purpose is to be partners for every life and protectors for every future. Our purpose encourages everything we do by creating a culture in which diversity is celebrated and inclusion assured, for our people, customers, and partners. We provide a platform for our people to do their best work and make an impact to the business, and we support our people's career ambitions. We pledge to make Prudential a place where you can Connect, Grow, and Succeed.

The incumbent is responsible for supporting the governance and quality management of empaneled medical providers, ensuring alignment with company policies and medical provider management standards. This includes contributing to the development and implementation of provider selection, evaluation, and onboarding processes, as well as conducting periodic reviews of providers engaged directly with Prudential Vietnam Assurance (PVA).

The role involves monitoring provider performance through ongoing quality assessment activities, such as audits, data analysis, and training, to ensure services are delivered in accordance with regulatory requirements, medical necessity standards, and company expectations. The incumbent also collaborates closely with medical providers and internal stakeholders to address service gaps, support continuous improvement initiatives, and facilitate discussions with providers to enhance service quality and customer experience in healthcare claims.

Job Description

1. Network Operations & Coordination

• Execute day-to-day operations of hospital and clinic network within the Direct Billing ecosystem, ensuring adherence to claims submission processes, workflows, and service standards.
• Act as the operational focal point for medical providers, supporting communication, issue resolution, and process alignment.
• Support provider onboarding activities, including validation of operational readiness and compliance with requirements.

2. Provider Performance & Claims Coordination

• Monitor provider performance indicators (e.g. TAT, accuracy, rejection/dispute cases) and escalate operational gaps or issues.
• Coordinate closely with Claims teams to ensure efficient end-to-end claims processing and resolve provider-related issues.
• Identify discrepancies, inefficiencies, or unusual patterns, including potential fraud or abuse, for further review.

3. Quality Assurance & Operational Improvement

• Support provider review, audit, or site visit activities, and follow up on corrective actions to improve service quality.
• Contribute to process standardization and workflow optimization initiatives.

Support digital and automation initiatives related to Direct Billing operations and claims workflows.

Job Accountability /

• The incumbent is responsible for supporting the development and implementation of the medical provider empaneling process, including identifying potential providers and coordinating negotiations for service agreements. This role ensures effective governance and quality management of medical provider services by establishing relevant processes, evaluation criteria, monitoring performance, and recommending remediation actions where necessary. The incumbent also participates in collaborative initiatives with medical providers to enhance service quality and customer experience in healthcare claims.

Job Requirements / Yêu cầu

a. Qualification

Degree in Insurance, Medial or Business Management.

b. Experience

Experience working in medical providers or continuously with medical providers.

Experience working in Network Management/Hospital Management positions at insurance companies.

Experience working related to healthcare products at insurance companies.

c. Knowledge, Skills & Attribute

Insurance/hospital or medical/nursing background

Possess knowledge on 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.