At AIA we've started an exciting movement to create a healthier, more sustainable future for everyone.
Sound like you Then read on.
About the Role
Responsible for determining operational excellence and customer satisfaction by empowering assessors through continuous training, reducing operational costs, ensuring consistent in validity and authorizing settlement of medical health. Responsible for handling complex policy cases which require special investigative skills or significant involvement and collaboration from different stakeholders to follow through together with MOH directives while fostering a culture of compliance, efficiency, and integrity.
Roles & Responsiblities:
- To conduct Amount Under clarification (AUC) and case management, regular audits, andhandle critical issues to identify Fraud, Waste and Abuse
- To ensure claim ad judication is in accordance with reasonable and customary charges and to review trending of doctors / members / agents that may or may not be in the watch list.
- To analyse and assess significant underwriting and claim cases with the aim of preventing fraud.
- To provide the ability to outline and implementprocess improvementstrategies andcost-saving measureswithin insurance operations.
- To coordinate activities of expert resources in relevant functions / departments in the effort to resolve the case and recommend operational improvements as appropriate
- To interpret the13th Schedule,Ministry of Health (MOH) letters, and assessment ofreasonable and customary charges and align with medical procedures and costs.
- To provide basic Medical Advisory for claims team members on disputed charges and appeal.
- To respond to inquiries of a technical or complex nature through case management.
- To conduct robust medical training aligned with technical aspects of claims processing.
- To mentor/coach and guide the TLs and assessors in robust decision making.
- May work with third parties and government authorities to support external investigation and prosecution of fraudulent cases
Minimum Job Requirements:
- Education: Bachelor's degree in health sciences, Life Sciences, Healthcare Management, Nursing or equivalent. A medical degree is advantageous but not mandatory.
- Experience: Minimum 5 years in health claims management, case management, or clinical advisory roles. Prior audit or quality assurance experience preferred.
- Certifications/Licenses: Any industry-related medical or healthcare certification (e.g., claims adjudication, healthcare audit, or insurance-specific certifications).
- Strong analytical and audit skills.
- Knowledge of insurance claims adjudication, MOH guidelines, and clinical coding.
- Excellent communication and stakeholder management.
- High proficiency in MS Office, claims platforms, and report automation tools
