Executive, Claim Investigation

2 days ago

Kuala Lumpur, Malaysia Prudential plc 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. We provide a platform for our people to do their best work and make an impact to the business, and 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.

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.

agent or client, appropriately to obtain necessary information in processing claims request.

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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