Medical Advisory, Case & Fraud Management, Specialist
AIA
Kuala Lumpur
Permanent
Full-time
1 month ago
At AIA we've started an exciting movement to create a healthier, more sustainable future for everyone. It's about finding new ways to not only better people's lives, but to better the communities and environments we live in. Encompassing our ambition of helping a billion people live Healthier, Longer, Better Lives by 2030. And to get there, we need ambitious people who believe in playing an important part in shaping that future. People seeking unmatched career and personal growth opportunities, who are driven to work with, and learn from some of the most inspiring and supportive leaders in the business. Sound like you Then read on. About the Role Responsible for providing technical medical expertise for claims decisions and resolution of customer enquiries and claims and managing healthcare related services provided to policy holders. Job Responsibilities: To ensure the Fraud tool is maintained and managed with care with insightful monthly analysis. Well-versed with medical coding, 13th Schedule, MOH letters, reasonable and customary charges. To conduct Amount Under Clarification (AUC) and case management, regular audits, and handle escalations to identify Fraud, Waste and Abuse. To ensure claim adjudication is in accordance with reasonable and customary charges. To review trending of doctors / members / agents that may or may not be in the watch list. To outline process improvement, cost saving measures, combating Fraud, Waste, and Abuse methods from audits. To perform ad-hoc analysis to support medical advisory, agencies, corporate solutions, operations, network management, product development and other relevant departments. To build claim guides that collaborates with clinical guides and cost containment with effective implementation. To conduct robust medical training aligned with technical aspects of claims processing including training to hospitals. To provide Medical Advisory including disputed charges, appeals and escalations. To ensure projects related with audits/ analysis and cost savings are carried out within the stipulated timeline. To actively engage and negotiate with stakeholders for recovery and remedial actions including doctors under supervision and non-participating list of doctors / agents / hospitals / members. To mentor/coach and guide the TLs and assessors in robust decision making. To proactively identify and collaborate on the needful system enhancement and process automation. Timely reporting and communication of all initiatives across all units in AIA. Performs other responsibilities and duties periodically assigned by supervisor in order to meet operational and/or other requirements. To participate and represent Medical Advisory, Case, and Fraud management in all necessary initiatives. Minimum Job Requirements: Candidate must possess at least a Bachelor's Degree or Diploma Min 2 years of medical claim experience Technical Skills: Claims assessment, medical report knowledge, Health Insurance Policy knowledge. Industry: Insurance, Third-Party Administrator, Hospitals, Clinics, Medical Labs. Language: English and Bahasa Malaysia. Build a career with us as we help our customers and the community live Healthier, Longer, Better Lives.
