Executive, Claim Investigation
1 week ago
Apply locations: Kuala Lumpur (Takaful)
Time type: Full time
Posted on: Posted 4 Days Ago
Job requisition id: 24110244
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 on 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 Executive, (Investigation Unit) is responsible for assisting the immediate supervisor:
- To process effectively complex claims by meeting and exceeding management's expectations on operational processes.
- To investigate suspicious claims, rule out suspected fraud, or establish non-disclosure/pre-existing illness, including out-of-office investigations and providing advice in areas of claims.
- To conduct field visits whenever required.
Responsibilities include:
- Investigating and ruling out suspicious/fraud claims by conducting a full assessment and pursuing suspicious elements found in the claimant, person covered, panel hospital, and doctors.
- Validating the information stated in the claims documents, assessing, and calculating the correct amount coverable, and making a correct decision in accordance with benefit terms & Claims SOP.
- Ascertaining the accurate data entry such as ICD10 Diagnosis Code, Surgery and Consultation Code (per PHA Schedule), and items charged per bills issued by the hospital.
- Liaising with hospital personnel including nurses and doctors via phone calls, emails, or writing letters as well as agents or clients, appropriately to obtain necessary information in processing claims requests.
- Coordinating with personnel from other related departments/sections within the company such as Underwriters, Endorsement (CES), and Compliance on post-investigation findings.
- Ensuring processing of all assigned cases within the agreed timeline as well as reviewing pending cases to be attended to within SOP and agreed timelines.
- Participating in product and technical training as well as working with the supervisor for additional training plans in acquiring and improving industry or technical knowledge.
- Ensuring the section/unit complies with all regulatory (internal and external) and corporate requirements, working closely with Risk, Compliance, Shariah, Actuarial, and other operational departments.
- Performing any other tasks given by HR, company, or department activities/directives as well as ad-hoc functions as requested by the Section Head or HOD.
Prudential is an equal opportunity employer. We provide equality of opportunity and benefits for all who apply and perform work for our organization 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.
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