Claims Senior Executive (Medical Doctor)

1. 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.

2. ACCOUNTABILITIES:

Claim Assessment & Decision Making

• Review and evaluate new claims, providing an initial decision or action plan.

• Handle complex cases requiring additional verification or investigation within SLA.

• Ensure claim decisions are accurate, fair, and compliant with internal guidelines, medical standards, and regulatory requirements.

Productivity & Efficiency

• Process standard cases with high accuracy and timeliness.

• Achieve daily throughput aligned with team targets while maintaining quality standards.

Quality & Compliance

• Maintain an exceptionally low error rate in claim decisions.

• Ensure strict adherence to SLA and all regulatory requirements for claim processes.

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

• Coordinate with internal teams to resolve complex cases and share best practices.

• Prepare and submit reports on claim status, productivity, and compliance metrics as required.

Perform additional tasks assigned by management to support operational goals, including internal medical knowledge sharing and training.

3. REQUIREMENTS:

- Education: Bachelor’s degree or higher, medical background is preferred.

- Experience: Prior experience in insurance or healthcare claims is an advantage.

- Technical Skills: Proficiency in MS Office, ability to analyze and interpret medical documents and apply insurance policy terms.

- Soft Skills: Analytical thinking, teamwork, time management; Detail-oriented, proactive, and integrity-driven.

- Language: Good command of English for communication and documentation.

4. CHALLENGES:

- Managing high volumes of claims while maintaining accuracy and compliance.

- Handling complex medical cases requires detailed assessment and coordination.

- Ensuring timely communication and resolution of customer complaints.

- Adapting to changes in policy terms, regulations, and system processes.