3 Case Management jobs in Malaysia

GREAT EASTERN WP. Kuala Lumpur, Federal Territory of Kuala Lumpur, Malaysia

GREAT EASTERN WP. Kuala Lumpur, Federal Territory of Kuala Lumpur, Malaysia

1 day ago Be among the first 25 applicants

To provide medical consultation and opinion in regard to claims pertinent to Guarantee Letter (GL) or Reimbursement / medical claim disputes or appeals / investigations / underwriting, and to ensure effective implementation of case management intervention in order to efficiently reduce or contain healthcare cost, without compromising healthcare quality and needs, in addition to development of quality assurance programmes or other relevant initiatives for organization.

• Medical advisory lead within and beyond operations divisions. To provide medical insights to various divisions within the company such as Medical Claims, Network Management, Call Centre, Customer Services, Product Management & Pricing, Strategic Business Development etc.
• To monitor and follow up with complex cases that require prolonged stay or due for discharge based on the length of stay planned / benchmarked; with the objective of limiting unwarranted extension of stay without compromising the care quality and to evaluate / approve for Top Up GL that fulfills criteria set within the proposed benchmark.
• To provide medical consultation and opinion in regard to admissibility and necessity of medical claims, fulfilment of policy contract definition in medical claims, investigation and underwriting decisions, as well as ad-hoc medical consultation and opinion in medical related queries.
• To communicate with panel specialists via call conference or virtual meetings regarding Professional Fee Queries and address overcharging issues or any issues on specialist’s fees to appropriate parties such as hospital management / hospital fee committee and Ministry of Health (MOH), medical councils, LIAM / PIAM as and when required, in accordance with the PHFSA Fee Schedule and reasonable & customary charges (R&C) guides.
• To develop / coach claim assessors through regular medical trainings and development / revision of internal claims guidelines to enhance their medical knowledge and competency in claim assessment to deliver services in keeping with the standards set.
• To involve in projects and/or initiatives for department / division process improvement.
• To conduct quality assurance checking on medical claims; to vet through periodical service report and follow up with relevant parties for remedial actions and its implementation as and when required.
• Take accountability in considering business and regulatory compliance risks and take appropriate steps to mitigate the risks.
• Maintain awareness of industry trends on regulatory compliance, emerging threats and technologies in order to understand the risk and better safeguard the company’s interest.
• Highlight any potential concerns / risks and proactively share the best risk management practices.
• In charge of fraud, waste and abuse (FWA) detection, resolution and prevention to minimize billing wastages by reviewing and analyzing trends and emerging patterns in hospital and doctors’ charges, implementing controls on claims overutilization.

The Person:

• Qualifications: Licensed practicing Medical Doctor (MBBS / MD) in good standing in medical community, preferably with clinical experience/ specialty in internal medicine, paediatrics, and surgical based. Postgraduate qualification in occupational health, family medicine, or any relevant field would be an added advantage. Experience in a public/ private hospital is essential. Experience in analysis, fraud detection is an added advantage.
• Working Experience: Minimum 5 years working experience in healthcare and/or insurance.
• Key Skills: Sound medical knowledge; knowledge of healthcare billing and medical terminology; strong business acumen with communication, analytical, problem solving, documentation and organization skills; strong negotiation and public relation skills.
• Key Knowledge: Knowledge in medical terminology, clinical knowledge; Proficiency in current healthcare delivery systems and hospital, patient management and billing system; insurance product and contractual wordings knowledge.
• Key Competencies: Customer service, product knowledge, medical knowledge, information gathering and analysis, policy interpretation and application, processes, procedures and policies.
• Demonstrate alignment with the organisation’s core values through expected behaviours.
• High level of integrity, take accountability of work and good attitude over teamwork.
• Take initiative to improve current state of circumstances and adaptable to embrace new changes.

How you succeed

• Champion and embody our Core Values in everyday tasks and interactions.
• Demonstrate high level of integrity and accountability.
• Take initiative to drive improvements and embrace change. Ver 1.0
• Take accountability of business and regulatory compliance risks, implementing measures to mitigate them effectively.
• Keep abreast with industry trends, regulatory compliance, and emerging threats and technologies to understand and highlight potential concerns/ risks to safeguard our company proactively.

Who we are

Founded in 1908, Great Eastern is a well-established market leader and trusted brand in Singapore and Malaysia. With over S$100 billion in assets and more than 16 million policyholders, including 12.5 million from government schemes, it provides insurance solutions to customers through three successful distribution channels – a tied agency force, bancassurance, and financial advisory firm Great Eastern Financial Advisers. The Group also operates in Indonesia and Brunei.

The Great Eastern Life Assurance Company Limited and Great Eastern General Insurance Limited have been assigned the financial strength and counterparty credit ratings of "AA-" by S&P Global Ratings since 2010, one of the highest among Asian life insurance companies. Great Eastern's asset management subsidiary, Lion Global Investors Limited, is one of the leading asset management companies in Southeast Asia.

Great Eastern is a subsidiary of OCBC, the longest established Singapore bank, formed in 1932. It is the second largest financial services group in Southeast Asia by assets and one of the world’s most highly-rated banks, with an Aa1 rating from Moody’s and AA- by both Fitch and S&P. Recognised for its financial strength and stability, OCBC is consistently ranked among the World’s Top 50 Safest Banks by Global Finance and has been named Best Managed Bank in Singapore by The Asian Banker.

To all recruitment agencies : Great Eastern does not accept unsolicited agency resumes. Please do not forward resumes to our email or our employees. We will not be responsible for any fees related to unsolicited resumes

• Seniority level Mid-Senior level

• Employment type Full-time

• Job function Health Care Provider
• Industries Insurance, Hospitals and Health Care, and Medical Practices

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AIA Malaysia Kuala Lumpur, Federal Territory of Kuala Lumpur, Malaysia

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AIA Malaysia Kuala Lumpur, Federal Territory of Kuala Lumpur, Malaysia

Join to apply for the Medical Advisory, Case & Fraud Management, Specialist role at AIA Malaysia

At AIA we’ve started an exciting movement to create a healthier, more sustainable future for everyone.

It’s about finding new ways to not only better people's lives, but to better the communities and environments we live in. Encompassing our ambition of helping a billion people live Healthier, Longer, Better Lives by 2030.

And to get there, we need ambitious people who believe in playing an important part in shaping that future. People seeking unmatched career and personal growth opportunities, who are driven to work with, and learn from some of the most inspiring and supportive leaders in the business.

Sound like you? Then read on.

About The Role

• To identify pattern of fraud, waste, and abuse in case management.
• To implement measures required for risk management.
• To conduct surgical and medical history check on claims .
• To identify breach of duty of good faith and non-disclosure
• To ensure risk are priced correctly and non-disclosed conditions excluded accurately and modified
• To perform prospective, concurrent and retrospective review of hospitalization
• To ensure cost containment measures without compromising on the care quality and service standards.
  
  

• To provide Medical Advisory including disputed charges, appeals and critical issues.
• To ensure the Fraud tool is maintained and handled with care with insightful monthly analysis.
• Proficient with medical coding, 13th Schedule, MOH letters, reasonable and customary charges.
• To conduct Amount Under Clarification (AUC) and case management, regular audits, and handle critical issues to identify Fraud, Waste and Abuse.
• To ensure claim adjudication is in accordance with reasonable and customary charges and to review trending of doctors / members / agents that may or may not be in the watch list.
• To outline process improvement, cost saving measures, combating Fraud, Waste, and Abuse methods from audits.
• To build claim guides that collaborates with clinical guides and cost containment with effective implementation.
• To conduct robust medical training aligned with technical aspects of claims processing including training to hospitals.
• To actively engage with collaborators for recovery and remedial actions including doctors under supervision and non-participating list of doctors / agents / hospitals / members.
• To mentor/coach and guide the TLs and assessors in robust decision making. To proactively identify and collaborate on the needful system improvement and process automation.
• To provide timely reporting and communication of all initiatives across all units in AIA.
• To participate and represent Medical Advisory, Case, and Fraud management in all vital initiatives.
  
  

• Candidate must possess at least a Bachelor's Degree or Diploma or equivalent experience
• Min 5 years of medical claim experience
• Technical Skills: Claims assessment, medical report knowledge, Health Insurance Policy knowledge.
• Industry: Insurance, Third-Party Administrator, Hospitals, Clinics, Medical Labs.
• Language: English and Bahasa Malaysia.
  
  

• Seniority level Mid-Senior level

• Employment type Full-time

• Job function Health Care Provider
• Industries Insurance

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