Claims Senior Executive (Medical Doctor)

JOB PURPOSE:
Responsible for managing health insurance claim assessments, including evaluating claim documents and insurance events, making settlement decisions, verifying additional information when required, and ensuring accurate calculation of approved expenses in compliance with policy terms, contractual provisions, and medical standards.
ACCOUNTABILITIES:
Claim Assessment & Decision Making
• Ensure claim decisions are accurate, fair, and compliant with internal guidelines, medical standards, and regulatory requirements.
• Handle complex cases requiring additional verification or investigation within SLA.
• Review and evaluate new claims, providing an initial decision or action plan.
Productivity & Efficiency
• Process standard cases with high accuracy and timeliness.
• Achieve daily throughput aligned with team targets while maintaining quality standards.
Quality & Compliance
• Ensure strict adherence to SLA and all regulatory requirements for claim processes.
• Maintain an exceptionally low error rate in claim decisions.
Customer Experience
• Respond promptly and professionally to customer inquiries and complaints, ensuring clear communication and resolution within agreed timelines.
• Provide accurate feedback and maintain a positive customer experience throughout the claim process
Collaboration & Reporting
• Prepare and submit reports on claim status, productivity, and compliance metrics as required.
• Coordinate with internal teams to resolve complex cases and share best practices.
Perform additional tasks assigned by management to support operational goals, including internal medical knowledge sharing and training.

Cập nhật gần nhất lúc: 2025-11-26 10:55:02