Claim Assessment Manager

Job Description Summary
The incumbent is responsible for leading and governing the end-to-end healthcare claims assessment function, ensuring alignment with company policies, operational standards, and regulatory requirements. This includes overseeing claims adjudication processes, quality assurance, risk management, and service delivery performance across both reimbursement and direct billing claims.
The role drives collaboration with internal and external stakeholders, to enhance claims quality, control costs, and improve customer experience. The incumbent is also accountable for managing team performance, driving continuous improvement initiatives, and ensuring compliance with audit and risk frameworks to support the company's healthcare business growth.
Job Description
• Lead and oversee daily healthcare claims operations, ensuring timely adjudication in compliance with Operating Manual, SLA, and quality standards.
• Govern claims assessment processes across reimbursement and direct billing, including complex case review, escalation handling, and decision oversight.
• Ensure effective implementation of quality assurance and audit frameworks (internal audit, QA, SOX/GwIA), maintaining high standards of claims accuracy and compliance.
• Act as the key liaison between Claims and cross-functional stakeholders (TPA, medical providers, Product, System, Risk, Finance) to resolve operational issues and improve claims processes.
• Drive cost control and risk management initiatives, including monitoring fraud, waste, and abuse (FWA), ensuring medical necessity and appropriate treatment evaluation.
• Oversee claims system utilization and improvement, ensuring accurate data capture, system updates, and alignment with automation initiatives.
• Lead communication and engagement with external stakeholders, including hospitals and TPA, to manage claims-related matters, disputes, and service quality issues.
• Drive continuous improvement projects to enhance productivity, turnaround time, and customer experience in claims servicing.
• Manage team performance, including resource planning, training, coaching, and performance monitoring to ensure consistent delivery of service excellence.
• Prepare and review reports on claims performance, quality metrics, and risk indicators for management decision-making.
Job Accountability / Trách nhiệm chính
• The incumbent leads and governs the healthcare claims assessment function, ensuring quality, SLA adherence, and compliance with company and regulatory standards. The role drives collaboration with internal stakeholders and external partners to identify risks, monitor fraud and abuse trends, and enhance claims effectiveness. The incumbent oversees complex adjudication, quality assurance, and cost control, while driving continuous improvement to strengthen operational efficiency and customer experience.