Claims Investigation

2 weeks ago

Kuala Lumpur, Malaysia Prudential plc Full time

Prudential's purpose is to help people get the most out of life. We will deliver our purpose by creating a culture in which diversity is celebrated and inclusion assured, for our colleagues, customers, and partners. We provide a platform for our people to do their best work and make an impact to the business, and in exchange, 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 to assist the immediate supervisor:

- To process effectively complex claims by meeting and exceeding management’s expectation on operational process.
- To investigate suspicious claims, to rule out suspected fraud or establish non
- disclosure/pre-existing illness, includes out of office investigations and provide advice in areas of claims.
- To conduct field visit whenever required.

The Executive, (Investigation Unit) is required to work closely with the Claims Team and other departments in delivering the role. Timely delivery in the assigned task and meeting department KPI and SLA while working with HOD to manage claims ratio.

1. To investigate and to rule out suspicious/ fraud claims by conducting full assessment and pursue suspicious elements found in claimant, person covered, panel hospital, doctors.

2. Validate the information stated in the claims documents, assess and calculate the correct amount coverable and make a correct decision accordance to benefit terms & Claims SOP.

3. Ascertain the accurate data entry such as ICD10 Diagnosis Code, Surgery and Consultation Code (per PHA Schedule) and items charged per bills issued by hospital. Ascertain the accurate data entry such as ICD10 Diagnosis Code, CI Code, Disability Code and Death Code as well as all relevant dates which impact the major claims benefit.

5. Coordinate with personnel’s from other related departments/section within the company such as Underwriters, Endorsement (CES), and Compliance on post investigation findings.

6. Ensure processing of all assigned cases within agreed timeline as well as review penders to be attended within SOP and agree timeline.

7. Participate in product and technical trainings as well as work with supervisor for additional training plans in acquiring and improving industry or technical knowledge.

8. Ensures section/unit complies with all regulatory (internal and external) and corporate requirements. To work closely with Risk, Compliance, Shariah, Actuarial and others operation department.

9. Any other tasks given by HR, company or department activities/directives as well as Ad-hoc function as requested by Section Head or HOD

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