Evaluates and processes medical insurance claims to ensure accuracy, policy compliance, and timely resolution. Operating in a 24/7 environment, the role balances medical review such as auditing billing reasonableness, treatment necessity, and diagnostic validity with operational front-line tasks, including phone support and risk mitigation.
Responsibilities
- Claims Assessment & Investigation: Evaluate medical claims, treatment plans, and billings against policy guidelines; investigate suspicious or complex claims before issuing payment guarantees.
- Operational Performance: Manage incoming and outgoing calls, meet turn-around times (TAT), maintain billing accuracy, and achieve operational KPIs.
- Shift Work: Operate on a 24/7 rotational schedule (AM, PM, Overnight) to maintain continuous service levels.
Qualifications
- Education: Minimum Diploma in Nursing or Allied Health sciences (Medical Degree preferred).
- Skills & Knowledge: Medical terminology (diseases/treatments), computer literacy, and fluency in English and Bahasa Malaysia.
- Experience: Background in Healthcare, TPA, Insurance, or Contact/Call Centres is advantageous (fresh graduates welcomed).
- Eligibility: Malaysian citizen or legal resident, comfortable with shift rotations and high-stress environments.
