claims operations

Overview

Who you'll be working for

What requirements you'll need to be eligible

• With 5 - 8 years experience in medical claims processing, including 2 years of supervisory experience
• With healthcare background is preferred
• With in-depth knowledge of medical terminology, billing codes (ICD 9, ICD 10, CPT) and medical insurance polices
• With depth knowledge on Fraud, Waste and Abuse (FWA), risk management or compliance frameworks
• Strong analytical, presentation and problem-solving capability
• Customer-oriented with excellent communication and interpersonal skills
• Proficiency in claims management system, data analysis tools and AI.

What you'll be doing on the job

• Leading and mentoring the Medical Claims team, setting performance goals, and monitoring KPIs.
• Review and assess medical claims , ensuring alignment with policy guidelines and service standards.
• Review and process complex claims cases and handle the case escalated by team members
• Prepare and analyse the claims data and reports
• Collaborate with HK Claims Team to conduct assessment and investigation if needed.
• Provide guidance and support to facilitate junior advisors in service delivery and daily operations
• Drive continuous improvement initiatives to optimize claims processing workflows
• Providing the trend of suspicious case to suggest a FWA dedection framework
• Updating the SOP and training note
• Preform daily QC to ensure the team's accuracy.

Consultant Contact