Manager, Heath Claims

Job Scope / Position Summary

• Responsible for daily assigned tasks in respect of Accident & Health claims in timely manner and within the company's claims manual and related policies and authority guidelines.
• Manage and settle legitimate claims including leading and monitor efficiency of team members on daily operation duties.
• Liaise with internal and external customers to achieve resolution on operational issues.
• Participate and complete timely on the Projects assign.
• To check, approve claims assessment & & authorize payment done by team members.
• Adhere to all claim operating guidelines and regulations.
• All other and related job as stated in the job scope (which may be revised).

Main Responsibility

Claims Operation

• Adhere to Claims Guidelines, related company policies and any authority guidelines to endure company is compliant & protected.
• Proactively address and / or escalate any operational issues and complaint to superior.
• Provide consultation, supervision and monitor the productivity and workflow of team to ensure team operating efficiently including monitoring team attendance and punctuality.
• Investigation on suspicious claims and finalized the claims on a timely basis in accordance with the agreed policies, processes and operational procedures.
• Assist team to handle complex cases such as Appeal claims, 2nd level complaints, high authority cases etc that may arise from time to time.
• To perform monthly post claims audit (both reimbursement and cashless cases).

Claims Costs

• Manage claims settlement costs and related claims expenses and ensure compliance with internal controls.
• Participate in proactive claims leakage management including claims training, activities leading to reduce loss ratio etc.
• Participate in Technical Deep Dive activities and others deemed relevant in managing claim costs & initiatives.

Claims Reserving

• Reserving and File / claims review are completed in accordance with BNM guidelines & Claims Operating guidelines in a timely manner.
• Assist in ensuring team's accuracy and completion for Claims file review.

Service Delivery

• Manage Third Party Administrator and ensuring they are performing according to SLA including resolving any arising operational concerns.
• Participate in TPA Management/Outsourcing/Own provider management where/when required.
• Main liaison officer and handler for Generali Malaysia's Medical Evacuation & Repatriation cases. (Note: In addition to Health, this role includes Travel and PA lines of businesses as well).
• Recruit, train and develop team members to achieve maximum potential and competency.
• Provide claims assessment advice to other Claims Units such as but not limited to Travel and PA (Internal Customer).

Governance

• Compliance – comply with the relevant requirements of the Insurance Act, 1996, Bank Negara Malaysia, PIAM, Company policies and procedures, Internal Audit requirements etc.
• Provide all kind of operational assistance & support for the Dept/Unit Lead.

Projects, TPA Management & Reporting

• Participate in projects initiatives to improve efficiency and productivity of the department/company.
• Participate in products development, claims reporting and UAT management.

Qualification and Experience Requirement

• Degree in any recognized Institution and/ or Diploma in Nursing.
• AMII/ ACII/ DMII or equivalent insurance qualifications (is an advantage).
• Minimum of 5 years' experience in and/ or similar role/ capacity.
• Good command of written and spoken English/ Bahasa Malaysia with strong communication skill.
• Good communication and negotiation skills.
• Result oriented, committed, team player, positive working attitude and good interpersonal skill.
• Ability to adapt and learn fast, diligent, trustworthy and have strong initiative to learn.
• Good analytical skills.
• IT literate, computer literate, especially in MS Word, Excel, Power Point.
• Ability and interest to lead and develop junior team members.
• Ability to multi-task, plan effectively and meet deadlines.
• Very good ability to strategize and drive execution.