This role is directly supporting the Claims Director to ensure all healthcare claims are processed accurately, promptly, transparently, and in strict compliance with policy terms and conditions.
The role is accountable for driving day-to-day team execution, taking ownership of tasks, coaching and mentoring team members in standardized claim adjudication, maintaining high standards of time management and logical thinking, guiding effective communication and negotiation with customers, hospitals/clinics, and TPAs, and delivering high-quality claim outcomes.
1. Team Operations, Coaching & SLA Performance Management
- Workload Allocation & Task Ownership: Organize, allocate, and monitor daily claim assessments for team members; foster a proactive mindset where members are willing to take on tasks and stay accountable for timely, high-quality deliverables.
- Coaching & Subordinate Guidance: Coach, guide, and share practical experience with team members to ensure professional, accurate, and standardized medical claim handling.
- Operational SLA & Speed Governance: Support the Claims Diretor in monitoring key benchmarks: turnaround times (TAT) for reimbursement and direct billing (GOP), initial case reserves, and settlement promptness in accordance with policy terms.
- Time Management & Case Prioritization: Apply strong time management skills to prioritize urgent and complex claims, actively preventing claim backlogs.
2. Technical Claims Adjudication, Delegation Authority & Negotiation
- Accurate Claim Assessment: Review and recommend appropriate settlement decisions for high-value or complex healthcare claims in strict accordance with policy wording, medical protocols, and ICD-10 code, etc.
- TPA & Direct Billing Coordination: Monitor and supervise TPA and direct billing operations; verify claims documents to ensure transparency and correctness.
- Negotiation & Dispute Communication: Communicate and negotiate claim resolutions with customers and hospitals professionally and persuasively, ensuring clear explanations while safeguarding company liability.
- Reporting & Escalation Management: Prepare claim report, submit claims that are over authority limit, and advise Claims Director on complex, sensitive, or disputed cases, etc.
3. Cost Containment, Anti-Fraud, QA Check & Department Support
- Medical Cost Containment & Anti-Fraud: Identify signs of fraud waste abuse and take prompt countermeasures.
- Quality Assurance (QA Check): Perform routine random quality checks across TPA, hospiatls/clinics to ensure calculation accuracy, complete claims documentation, and procedural adherence.
- Digital Transformation: Actively adopt digital tools (auto-adjudication, OCR, mobile claim tracking) to streamline healthcare claims processing.
- Department Targets & Direct Manager Tasks: Able to complete duties to support Department targets and company objectives; and complete tasks when assigned by Direct manager.
Key Relationships - Direct Manager
Claims Director
Key Relationships - Direct Reports
Manages an assessment team of 5-10 members
Key Relationships - Internal Stakeholders
Internal function Division in company
Key Relationships - External Stakeholders
Customers, TPAs, Hospitals & Clinics, Regulators, etc.
Success Profile - Qualification and Experiences
- Education: Bachelor's degree or higher in Medicine, Pharmacy, Public Health, Insurance, Finance, Economics, or a related field. Medical/Pharmacy clinical background is an advantage
- Professional Experience: Minimum 3 years of direct hands-on experience in healthcare claims assessment and adjudication at leading insurance companies, TPA, or large hospital billing departments.
- Team Management Experience: At least 2 years of experience managing a team of 5+ members (preferably in claims operations).
- English Intermediate: only requires ability to listen, read, and write in English (able to comprehend English insurance wordings, and draft written communications/emails, etc.).