Claims Representative

Cigna; Kuala Lumpur; On-site; MYR 100,000 - 150,000; Full time

Job summary

A leading healthcare provider in Kuala Lumpur is seeking a dedicated Claims Processor. In this role, you will handle claims for medical expenses, ensuring compliance with policies while providing stellar service to clients and providers. You should possess excellent organizational and communication abilities, with at least 1-2 years of relevant experience. The ideal candidate will thrive in a fast-paced environment and be capable of working both independently and collaboratively. Join us to help improve health outcomes for our customers.

Qualifications

• 1-2 years of experience in a similar role.
• Claims processing or insurance experience is preferred.
• Excellent organizational and communication skills.
• Strong administration and Microsoft Office skills.

Responsibilities

• Process claims from members and providers.
• Maintain files for authorizations and other reports.
• Assess and process claims in line with policy coverage.
• Collaborate with stakeholders to resolve queries.

Skills

Organizational skills

Communication skills

Administration skills

Microsoft Office proficiency

Time management

Flexible and adaptable approach

Job description

JOB PURPOSE

The job holder is responsible of serving providers and insurance companies by determining requirements, answering inquiries, resolving problems, fulfilling requests and maintaining database. He/She is responsible for processing as per terms of benefits. He/She should provide accurate and relevant medical coverage details and maintain pre-approvals and claims processing as per the defined terms and policies of the organization.

RESPONSIBILITIES AND DUTIES

• Processes claims from members and providers.
• Assists queries from providers and payers via phone calls or e-mails.
• Maintains files for authorizations and other reports.
• Assesses and processes claims in line with the policy coverage and medical necessity.
• Be fully versed with medical insurance policies for various groups / beneficiaries.
• May assist in training colleagues and asked to share knowledge.
• Accurately assesses eligibility within the policy boundaries.
• Monitors and maintains the claims processing as per the defined terms and policy of the organization.
• Achieves required processing targets assigned by the team leader on daily, weekly and monthly basis.
• Monitors the qualitative and quantitative measures for claims & pre-approvals.
• Ensures compliance to any changes in terms of system parameters or process.
• Maintains quality as per framework for accuracy.
• Maintains productivity and responsiveness to the work allocated.
• Collaborate with other stakeholders / teams to resolve queries including complex queries.
• Actively support all team members to enable operational goals to be achieved.
• Meet or exceed Service Level Agreement requirements, team KPI(s), monthly quality audit scores and NPS (Net Promoter Score).
• Assessing and processing claims for medical expenses while always bearing in mindthe importance of medical confidentiality.
• Accurate data input to the system applications.
• Positioning him/herself analytically and critically in the context of cost management and in respect of existing working methods.
• Following up own workload (volume and timing): keeping an eye on chronology and processing time of the work volume and taking suitable actions.
• Participate efficiently in processing the flow of claims: inform the supervisor about claims lacking clarity and about possible ways of optimizing the processes.
• A sustained effort towards high-quality claims handling, accurate reimbursements and fast transactions are important motivators.
• Monitor and highlight high-cost claims and ensure relevant parties are aware.
• Follow Claim Manual and SOP strictly, adjudicate claims according to benefit policies, and meet both financial/procedure accuracy and TAT target on claims adjudication.
• Adjust error claims according to actual situation.
• Well handle recoupment and reconciliation work, communicate with providers and members via call and email for collection and explanation.
• Work with cross function teams, such as Finance, CSR, Eligibility, Network, Client Management, etc. Ensure recoupment work go smoothly.
• Actively support Team Leader and work with claim colleagues to enable all operational goals to be achieved

KNOWLEDGE, SKILLS AND EXPERIENCE

• At least 1-2 years of experience performing a similar role.
• Experience of working for an international company, preferred but not essential.
• Claims processing or insurance experience, preferred but not essential.
• Broad awareness of medical terminology, advantageous.
• Excellent organizational skills, capable of following and contributing to agreed procedure.
• Strong administration awareness and experience, essential.
• Strong skills in Microsoft Office applications, essential.
• First class written and verbal communication skills, essential.
• Ability to communicate across a diverse population, essential.
• Capable of working independently, or as part of a team.
• Good time management, ability to work to tight deadlines.
• Flexible and adaptable approach, sometimes working in a fast-paced environment.
• Passion for achieving agreed objectives.
• Confident in calling out when facing issues.
• Should be flexible to work in shifts and on staggered weekends for overtime.

COMMUNICATIONS AND WORKING RELATIONSHIPS

The job holder must ensure building strong effective relationships with all his matrix partners and demonstrating approachability and openness. He/ She must be able to foster strong internal and external communication standards.

About The Cigna Group

Cigna Healthcare, a division of The Cigna Group, is an advocate for better health through every stage of life. We guide our customers through the health care system, empowering them with the information and insight they need to make the best choices for improving their health and vitality. Join us in driving growth and improving lives.