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Investigation Specialist

1 week ago

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

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.

The Investigation Unit plays a crucial role in this mission, responsible for assisting the immediate supervisor in processing complex claims effectively and efficiently.

Key responsibilities include:

  1. 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.
  2. To conduct field visits whenever required to gather information.

Additional responsibilities include:

  1. To investigate and rule out suspicious/fraud claims by conducting full assessments and pursuing suspicious elements found in claimants, person covered, panel hospitals, doctors.
  2. Validate the information stated in the claims documents, assess and calculate the correct amount coverable and make decisions in accordance with benefit terms and Claims SOP.
  3. Ascertain accurate data entry such as ICD10 Diagnosis Code, Surgery and Consultation Code (per PHA Schedule) and items charged per bills issued by hospital.
  4. Liaise with hospital personnel including nurses and doctors via phone-call/email/writing letters as well as agents or clients, appropriately to obtain necessary information in processing claims requests.
  5. Coordinate with personnel from other related departments/sections within the company, such as Underwriters, Endorsement (CES), and Compliance on post-investigation findings.
  6. Ensure processing of all assigned cases within agreed timelines as well as review pending cases to be attended within SOP and agree timelines.
  7. Participate in product and technical trainings as well as work with supervisors for additional training plans in acquiring and improving industry or technical knowledge.
  8. Ensure section/unit complies with all regulatory (internal and external) and corporate requirements, working closely with Risk, Compliance, Shariah, Actuarial and other operational departments.
  9. Perform any other tasks given by HR, company, or department activities/directives, as well as ad-hoc functions requested by Section Heads or HODs.