Job Scope / Position Summary
- Responsible for daily assigned tasks in respect of Accident & Health claims in timely manner and within the companys claims manual and related policies and authority guidelines.
- Manage and settle legitimate claims including leading and monitor efficiency of team members on daily operation duties.
- Liaise with internal and external customers to achieve resolution on operational issues.
- Participate and complete timely on the Projects assign.
- To check, approve claims assessment & & authorize payment done by team members.
- Adhere to all claim operating guidelines and regulations.
- All other and related job as stated in the job scope (which may be revised).
Main Responsibility
Claims Operation
- Adhere to Claims Guidelines, related company policies and any authority guidelines to endure company is compliant & protected.
- Proactively address and / or escalate any operational issues and complaint to superior.
- Provide consultation, supervision and monitor the productivity and workflow of team to ensure team operating efficiently including monitoring team attendance and punctuality.
- Investigation on suspicious claims and finalized the claims on a timely basis in accordance with the agreed policies, processes and operational procedures.
- Assist team to handle complex cases such as Appeal claims, 2nd level complaints, high authority cases etc that may arise from time to time.
- To perform monthly post claims audit (both reimbursement and cashless cases).
Claims Costs
- Manage claims settlement costs and related claims expenses and ensure compliance with internal controls.
- Participate in proactive claims leakage management including claims training, activities leading to reduce loss ratio etc.
- Participate in Technical Deep Dive activities and others deemed relevant in managing claim costs & initiatives.
Claims Reserving
- Reserving and File / claims review are completed in accordance with BNM guidelines & Claims Operating guidelines in a timely manner.
- Assist in ensuring teams accuracy and completion for Claims file review.
Service Delivery
- Manage Third Party Administrator and ensuring they are performing according to SLA including resolving any arising operational concerns.
- Participate in TPA Management/Outsourcing/Own provider management where/when required.
- Main liaison officer and handler for Generali Malaysias Medical Evacuation & Repatriation cases. (Note: In addition to Health, this role includes Travel and PA lines of businesses as well).
- Recruit, train and develop team members to achieve maximum potential and competency.
- Provide claims assessment advice to other Claims Units such as but not limited to Travel and PA (Internal Customer).
Governance
- Compliance comply with the relevant requirements of the Insurance Act, 1996, Bank Negara Malaysia, PIAM, Company policies and procedures, Internal Audit requirements etc.
- Provide all kind of operational assistance & support for the Dept/Unit Lead.
Projects, TPA Management & Reporting
- Participate in projects initiatives to improve efficiency and productivity of the department/company.
- Participate in products development, claims reporting and UAT management.
Qualification and Experience Requirement
- Degree in any recognized Institution and/ or Diploma in Nursing.
- AMII/ ACII/ DMII or equivalent insurance qualifications (is an advantage).
- Minimum of 5 years experience in and/ or similar role/ capacity.
- Good command of written and spoken English/ Bahasa Malaysia with strong communication skill.
- Good communication and negotiation skills.
- Result oriented, committed, team player, positive working attitude and good interpersonal skill.
- Ability to adapt and learn fast, diligent, trustworthy and have strong initiative to learn.
- Good analytical skills.
- IT literate, computer literate, especially in MS Word, Excel, Power Point.
- Ability and interest to lead and develop junior team members.
- Ability to multi-task, plan effectively and meet deadlines.
- Very good ability to strategize and drive execution.
