Claims Manager

2 days ago


Kuala Lumpur, Malaysia Inova Care International Full time

**Location**: Kuala Lumpur Malaysia

**Employment Type**: Full-Time

**Industry**: Healthcare / Insurance / Third-Party Administration (TPA)

**About the Role**

This role is critical in ensuring accurate, compliant, and timely claims processing while driving operational excellence and supporting clinical integrity across our provider network.

**Key Responsibilities**
- Manage end-to-end claims adjudication processes for inpatient, outpatient, emergency, and dental services
- Ensure claims are reviewed based on medical necessity, benefit coverage, member eligibility, and policy exclusions
- Collaborate with medical review teams to resolve complex or questionable claims
- Monitor claims turnaround time, accuracy metrics, and compliance with SLAs
- Lead fraud detection and abuse prevention efforts in coordination with compliance and clinical teams
- Liaise with finance for timely liquidation and reconciliation of processed claims
- Maintain documentation workflows and ensure proper issuance of Explanation of Benefits (EOBs)
- Provide insights and recommendations for process improvement and automation initiatives
- Participate in audits, client reviews, and regulatory reporting as needed

**Qualifications**
- Minimum 5 years of experience in claims management within a TPA or health insurance setting
- **SCI or CGI certification** is required
- Strong understanding of **medical coding systems** and **rules-based adjudication frameworks**:

- Familiarity with healthcare benefit structures, exclusions, and provider fee schedules
- Excellent analytical, organizational, and communication skills
- Proficiency in claims systems and reporting tools
- Ability to lead teams and collaborate cross-functionally with clinical, finance, and provider relations units

**What We Offer**
- Opportunity to work in a dynamic and mission-driven organization
- Professional development and certification support
- Collaborative and inclusive work environment

Pay: From RM7,000.00 per month

**Benefits**:

- Flexible schedule

License/Certification:

- SCI / CGI Certification (BCP, PGI, HI) (required)

Work Location: In person


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