Medical Advisory, Case

4 weeks ago

Kuala Lumpur, Malaysia AIA Full time

At AIA we’ve started an exciting movement to create a healthier, more sustainable future for everyone.
- It’s about finding new ways to not only better people's lives, but to better the communities and environments we live in. Encompassing our ambition of helping a billion people live Healthier, Longer, Better Lives by 2030._
- And to get there, we need ambitious people who believe in playing an important part in shaping that future. People seeking unmatched career and personal growth opportunities, who are driven to work with, and learn from some of the most inspiring and supportive leaders in the business._

Sound like you? Then read on.

About the Role

1. To identify pattern of fraud, waste, and abuse in case management.

2. To implement measures required for risk management.

3. To conduct surgical and medical history check on claims.

4. To identify breach of duty of good faith and non-disclosure

5. To ensure risk are priced correctly and non-disclosed conditions excluded accurately and modified

6. To perform prospective, concurrent and retrospective review of hospitalization

7. To ensure cost containment measures without compromising on the care quality and service standards.

Job Responsibilities:

- To provide Medical Advisory including disputed charges, appeals and critical issues.
- To ensure the Fraud tool is maintained and handled with care with insightful monthly analysis.
- Proficient with medical coding, 13th Schedule, MOH letters, reasonable and customary charges.
- To conduct Amount Under Clarification (AUC) and case management, regular audits, and handle critical issues to identify Fraud, Waste and Abuse.
- To ensure claim adjudication 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 outline process improvement, cost saving measures, combating Fraud, Waste, and Abuse methods from audits.
- To build claim guides that collaborates with clinical guides and cost containment with effective implementation.
- To conduct robust medical training aligned with technical aspects of claims processing including training to hospitals.
- To actively engage with collaborators for recovery and remedial actions including doctors under supervision and non-participating list of doctors / agents / hospitals / members.
- To mentor/coach and guide the TLs and assessors in robust decision making. To proactively identify and collaborate on the needful system improvement and process automation.
- To provide timely reporting and communication of all initiatives across all units in AIA.
- To participate and represent Medical Advisory, Case, and Fraud management in all vital initiatives.

Minimum Job Requirements:

- Min 5 years of medical claim experience
- Technical Skills: Claims assessment, medical report knowledge, Health Insurance Policy knowledge.
- Industry: Insurance, Third-Party Administrator, Hospitals, Clinics, Medical Labs.
- Language: English and Bahasa Malaysia.
- Build a career with us as we help our customers and the community live Healthier, Longer, Better Lives._

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