Claims Assessor

LUMA's mission is to ensure our members live healthier, longer lives by providing them brilliantly simple insurance plans. We provide a range of simple, smart policies to global residents, expatriates, local nationals and groups of all sizes. At LUMA, we continuously adopt new innovations to make insurance easy to understand and easy to use.

The Claims Assessor, will serve medical insurance customers by determining insurance coverage; examining and resolving medical claims; documenting actions; maintaining quality customer services; ensuring legal compliance.

Responsibilities:

• Receive, review, and assess reimbursement claims submitted by members through designated submission channels, ensuring that required claim forms, medical documents, invoices, receipts, and supporting documents are complete and valid for assessment.
• Assess claim eligibility and coverage based on the submitted medical information and applicable policy terms and conditions, including benefits, limits, exclusions, waiting periods, pre-existing conditions, deductibles, co-payments, and other policy provisions.
• Review the reasonableness and appropriateness of medical expenses by evaluating diagnoses, treatment details, medical services, and itemized charges, and identify cases requiring further medical review or clarification.
• Manage incomplete or pending claims by identifying missing information and coordinating with members, hospitals, healthcare providers, Customer Service, or other relevant parties to obtain additional documents or clarification required to complete the claim assessment.
• Assess complex, high-cost, or questionable claims and escalate cases requiring further medical, policy, or coverage review to the Medical Consultant, Claim Manager, insurer, or other relevant parties.
• Process approved claims for payment by accurately recording claim information, benefit calculations, assessment decisions, and payment details in the claim system, and coordinating with insurers and other teams to ensure timely payment processing.
• Ensure claim quality, compliance, and timely case management by monitoring outstanding and pending claims, following up proactively, meeting established SLAs, maintaining accurate claim records, and complying with company policies, procedures, and applicable insurance requirements.

Qualifications:

• Medical background
• Experience in the healthcare, insurance, or related industry
• Excellent communication skills in both Thai and English
• Strong analytical skills with sound judgment and the ability to prioritize work
• High attention to detail with the ability to work effectively under pressure

Competitive package:

• 12 days of Annual leave per year
• Social Security
• Provident Fund
• Medical Insurance