Sr. Specialist - AZAY Claim Reimbursement
THAILAND
Job description
Job Summary :
Being responsible for claim quality audit and report preparation in timeline. Also, claim analysis project and the activities related to its results.
Responsibilities :
1. Claim Quality Audit
- Regular claim quality review and feedback result to team.
- 100% checking total Major and Death claims.
- Random checking Reimbursement claims both individual and group (E-claim submission, Auto-Paid).
- Random checking Hospital Assessment claims both individual and group.
- Random checking Fax Claim cases.
- Best Practice Sharing case study in monthly meeting to team.
- QA Monthly report and KRI report preparation
2. Claim Monthly Report
- Regular review and analyze claims data from IT.
- Prepare the claim monthly report to team.
- Find out the abnormal claim pattern in various dimensions e.g. number of claim transactions, number of claimant, distribution channels and hospitals etc.
- Cooperation with team and take actions in claims part such as high claim cases by doing not renew process, issue agent warning letter, closely claim monitoring and add their name list in UC file
3. Claims Analysis
- Analyse big claim data to find out the abnormal claims pattern.
- After getting the analytic report, support by
• Reviewing claim data as the criteria setting e.g. claim visiting count, early claim count ,last claim visiting duration etc.
• 1st step of visual inspection to screen and select the suspicious cases.
• 2nd step of details investigation by reviewing all documents (application, all coverage, claim history, claim documents, agent details, claims payment amount.
• Summary total suspicious cases and all actions.
• Take actions as team decision such as not renew process, issue agent warning letter, closely claim monitoring and add their name list in UC file.
- Regularly practice for this function as above procedure.
Qualifications :
- Bachelor’s in Nursing, Business of Sciences (Medical Technology), or other related field
- 3 to 5 years experience in Nursing practice,Claims Management, or other related fields in insurance industry
Any AI-future skills e.g., ChatGPT, or CoPilot 365, will be an advantage.