Claim Assessment Senior Specialist

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• The incumbent need to follow the Operating Manual as guidance to standard operating process in administering all types of claims, including both reimbursement and direct billing cases.
• He/She is responsible for processing daily claims volume within the expected quality standards, standard processing time SLA, and overall turnaround time, including cases involving second-level review for adjudication and approval.
• The regular assessment process may subject to change as when there is system improvement arise from automation which the assessor is required to constantly follow through the change and update diligently to ensure the assessment comment/decision is being captured and escalated.
• The incumbent is required to update claims decisions, assessment comments, and case status accurately in the relevant systems, including RCS, TPA portal, or other systems in use. In situation the automation is not supporting, the incumbent will require to support the automation manager to rectify reason of the productivity not capture and continue to produce manual record.
• The incumbent is responsible for rectifying any incorrect processing or claim decision in a timely manner, with proper justification and escalation in accordance with internal procedures.
• All complex or investigation-related cases, including cases involving out-of-system communication, must be properly documented, with relevant information uploaded into the required systems and escalated for approval where applicable.
• When claims assessor involved in investigation cases which may have out of system communications, claims assessor need to ensure all information are to upload in the RCS and document stored in FileNet, or other systems in use.
• For cases requiring additional clarification, especially those with potential complaint exposure, the incumbent may be required to communicate with customers, hospitals, or providers professionally and in accordance with company guidance.
• The incumbent is expected to maintain productivity and quality standards, provide explanation on performance gaps when required, and support continuous process compliance in line with internal risk and quality requirements.
• He/She is expected to participate in training, development activities, and any other duties or projects assigned by management from time to time.
• Claims adjudicator is required to perform audit on monthly claims cases. Interchangeable (Direct billing versus reimbursement cases in Quality Assurance) in response to the evaluation to ensure quality of assessment achieve.
• This is in effort to support on TPA audit, QA audit, Claims assessors are require to perform the QA extracted cases interchangeably on peers processed cases in according to GwIA guideline and Sox audit.
• Specific focus to focus on decision, process compliance on all document, calculation of payment according to product's table of benefits, diagnosis with appropriate treatment and LOS in accordance with good standard of medical necessary practice with all FWA include unnecessary LOS to be recorded and communicated to providers/TPA, to ensure the risk control is within the HC quality assurance framework.
• He/She will need to prepare case study on out of force policy coverage or exgratia exceptional handling proposal.
• Continuously attend / involve with training for personal and career development.
• Undertake projects / other work and duties allocated by management as and when required.