Claim Assessor

Job Description Summary
The incumbent is responsible for administering daily healthcare claims in accordance with the Operating Manual and internal guidelines, including both reimbursement and direct billing cases. This includes accurate claims assessment, timely status updates, diligent follow-up with hospitals and providers for approval or denial decisions within stipulated service levels, proper system updates, and calculation of payable benefits while considering fraud, waste and abuse cost avoidance without compromising the Company's interests.
The incumbent is also responsible for executing the direct billing process by ensuring accurate registration, adjudicating claims through to payment, and maintaining quality and process compliance in line with internal risk and quality requirements, thereby contributing to the Company's healthcare service objectives.
Job Description
• 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 incumbent is required to assess claims accurately based on policy coverage, supporting documents, table of benefits, medical necessity and diagnosis with appropriate treatment and LOS in accordance with good standard of medical necessary practice with all FWA include unnecessary LOS, while ensuring proper calculation of payable benefits.
• He/She is required to identify and escalate suspicious, unclear, or exceptional cases, including potential fraud, waste and abuse concerns, to the supervisor or manager for further review and decision.
• 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.
• 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.
• 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.
Job Accountability/ Trách nhiệm chính
• To perform daily adjudication of healthcare claims cases, including reimbursement and direct billing claims, in accordance with the Operating Manual; to ensure accurate assessment, proper system update, calculation of payable benefits, and review of Medical Service Provider charges to meet medical necessary and appropriate charges with proper procedures being executed.