Senior Claims Professional

3 days ago


Kuala Lumpur, Kuala Lumpur, Malaysia Prudential Hong Kong Limited Full time

Job Description:

We are seeking a highly skilled Senior Claims Professional to join our team at Prudential Hong Kong Limited. As a key member of our Claims Department, you will be responsible for detecting and preventing Medical Claims Fraud, Waste and Abuse (FWA) in order to ensure the long-term sustainability of our portfolio.

With a strong knowledge of medical and insurance processes, you will perform training and audits, maintain system rules and guidelines to equip the Claims Department with the necessary skills to eliminate leakages.

The incumbent will lead in managing staff and ensuring tasks assigned to team members are completed within the given time to meet expectations on operational processes.

You will assist the Senior Manager in leading and coordinating team members to achieve the company's goals in providing support and guidance to the Claims Department via assessor knowledge, guidelines, systems, technology, etc.

Responsibilities:
  • Manage and provide claims training for claims assessors to ensure skills are continuously improved through external trainings or customized technical training programs.
  • Provide and support claims training to other departments or business partners.
  • Manage and perform claims review on claims assessors' cases as part of the claims authority upgrade process.
  • Manage and report on claims/compliance audits to ensure quality assessment and compliance are achieved and identify any improvement areas.
  • Perform regular reviews of underwriting guidelines to ensure relevance, competitiveness, and to drive operational efficiency while maintaining good risk management and long-term sustainability of the portfolio.
  • Work closely with other departments and vendors in delivering a robust claims process flow.
  • Develop and maintain rules in the claims system for STP and identify opportunities that provide operational efficiency, support business growth, and seamless customer experience.
  • Leverage internal and external data to understand current state, trends, and opportunities in improvement/growth areas.
  • Support improvement in SLA and minimize penders through identifying improvement opportunities, automation, streamlining processes, and guidelines.
  • Support improvement in onboarding NPS through various initiatives, manage and monitor team performance in meeting departmental service expectations, and deliver excellent service quality to customers.


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