Claims Representative

4 days ago

Kuala Lumpur, Kuala Lumpur, Malaysia Cigna International Health Services Sdn Bhd Full time

This job is a Claims Representative. You might like this job because you'll process claims, assist with inquiries, maintain files, and ensure accurate medical coverage details, all while meeting processing targets and ensuring compliance with policies.

Salary: RM 3000 - RM 4500

Employment Type: Full-Time

Posted: few days ago

Job Description

JOB PURPOSE

The job holder is responsible for serving providers and insurance companies by determining requirements, answering inquiries, resolving problems, fulfilling requests, and maintaining the database. He/She is responsible for processing as per terms of benefits. He/She should provide accurate and relevant medical coverage details and maintain pre-approvals and claims processing as per the defined terms and policies of the organization.

RESPONSIBILITIES AND DUTIES

  1. Processes claims from members and providers.
  2. Assists queries from providers and payers via phone calls or e-mails.
  3. Maintains files for authorizations and other reports.
  4. Assesses and processes claims in line with the policy coverage and medical necessity.
  5. Be fully versed with medical insurance policies for various groups/beneficiaries.
  6. May assist in training colleagues and share knowledge.
  7. Accurately assesses eligibility within the policy boundaries.
  8. Monitors and maintains the claims processing as per the defined terms and policy of the organization.
  9. Achieves required processing targets assigned by the team leader on a daily, weekly, and monthly basis.
  10. Monitors the qualitative and quantitative measures for claims & pre-approvals.
  11. Ensures compliance with any changes in terms of system parameters or processes.
  12. Maintains quality as per framework for accuracy.
  13. Maintains productivity and responsiveness to the work allocated.
  14. Collaborates with other stakeholders/teams to resolve queries including complex queries.
  15. Actively supports all team members to enable operational goals to be achieved.
  16. Meets or exceeds Service Level Agreement requirements, team KPI(s), monthly quality audit scores, and NPS (Net Promoter Score).
  17. Assesses and processes claims for medical expenses while always bearing in mind the importance of medical confidentiality.
  18. Accurate data input to the system applications.
  19. Positions him/herself analytically and critically in the context of cost management and in respect of existing working methods.
  20. Follows up own workload (volume and timing): keeping an eye on chronology and processing time of the work volume and taking suitable actions.
  21. Participates efficiently in processing the flow of claims: informs the supervisor about claims lacking clarity and about possible ways of optimizing the processes.
  22. A sustained effort towards high-quality claims handling, accurate reimbursements, and fast transactions are important motivators.
  23. Monitors and highlights high-cost claims and ensures relevant parties are aware.
  24. Follows Claim Manual and SOP strictly, adjudicates claims according to benefit policies, and meets both financial/procedure accuracy and TAT target on claims adjudication.
  25. Adjusts error claims according to the actual situation.
  26. Handles recoupment and reconciliation work, communicates with providers and members via call and email for collection and explanation.
  27. Works with cross-functional teams, such as Finance, CSR, Eligibility, Network, Client Management, etc. Ensure recoupment work goes smoothly.
  28. Actively supports Team Leader and works with claim colleagues to enable all operational goals to be achieved.
Job Requirements

KNOWLEDGE, SKILLS AND EXPERIENCE

  1. At least 1-2 years of experience performing a similar role.
  2. Medically qualified as a doctor.
  3. Experience of working for an international company, preferred but not essential.
  4. Claims processing or insurance experience, preferred but not essential.
  5. Broad awareness of medical terminology, advantageous.
  6. Excellent organizational skills, capable of following and contributing to agreed procedure.
  7. Strong administration awareness and experience, essential.
  8. Strong skills in Microsoft Office applications, essential.
  9. First-class written and verbal communication skills, essential.
  10. Ability to communicate across a diverse population, essential.
  11. Capable of working independently, or as part of a team.
  12. Good time management, ability to work to tight deadlines.
  13. Flexible and adaptable approach, sometimes working in a fast-paced environment.
  14. Passion for achieving agreed objectives.
  15. Confident in calling out when facing issues.
  16. Should be flexible to work in shifts and on staggered weekends.

COMMUNICATIONS AND WORKING RELATIONSHIPS

The job holder must ensure building strong effective relationships with all his matrix partners and demonstrating approachability and openness. He/She must be able to foster strong internal and external communication standards.

Skills
  1. Medical Insurance Claims
  2. Claims Processing
  3. Biomedical Sciences
  4. Medical Terminology
Company Benefits

Receive a generous travel allowance to support your commuting needs, ensuring a smooth and stress-free journey to work.

Wellness Initiatives

We prioritize your health and well-being by offering fresh fruits daily in the office.

Global Exposure

Gain international experience and collaborate with a diverse, multinational team, enhancing your global perspective and professional growth.

Diverse Insurance Options

Benefit from our comprehensive insurance package which includes five different types of coverage to meet your varied needs.

Achieve a better work-life balance with our hybrid work model, allowing you to work from home on designated days.

Additional InfoCompany Activity

Last active - few hours ago

Experience Level

#NoExperienceNeeded

Entry Level

Job Specialisation

Corporate Finance / Investment, Doctor / Health Specialist, Nurse / Medical Support

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