KEY ACCOUNTABILITIES :
- Providing consultation to TPA and Claims Team Members regarding medical aspect of claims to validate their eligibility.
- Supporting the handling of fraud detection, complex cases, hospital admission cases, complaint cases and denied claims.
- Capability to medically justify decisions within a given authority limit on any medical claim related case.
- Coordinating with re-insurer to validate final decision when necessary.
- Monitoring, reviewing, and auditing services of Third-Party Administrator (TPA) or Hospital depending and claim management processes.
- Supporting the development of the Medical Claims Team skills and knowledge.
- Coordinating with external parties such as third party providers, medical providers and/or co-insurance companies to obtaining medical records, claims records, and policy details to support claims assessment.
- Responsible for claims verification, claim approval, and payment approval in the system within authority limit.
- Acting as a company representative to provide explanations, declaration to the OIC or court in case of claims dispute or claims litigation including information preparation, coordination with external medical consultant, coordination with lawyer, and testifying on behalf of the company until the case is closed.
- Any other job functions assigned by supervisor that deem to necessary
EXPERIENCE AND QUALIFICATIONS :
