Manager, Medical Advisor & Case Management

Great Eastern; Kuala Lumpur; On-site; MYR 80,000 - 120,000; Full time

Job summary

A leading insurance company in Kuala Lumpur is seeking a Manager, Medical Advisor & Case Management to provide critical medical consultation in claims related to healthcare. The role involves monitoring complex cases, overseeing fraud detection, and developing quality assurance initiatives. Candidates must be a licensed medical doctor with at least 5 years of experience in healthcare or insurance, demonstrating sound medical and analytical skills. A postgraduate qualification is an advantage, and strong business acumen is essential.

Qualifications

• Minimum 5 years working experience in healthcare and/or insurance.
• Preferably with clinical experience/specialty in internal medicine, pediatrics, or surgery.
• Experience in analysis and fraud detection is an added advantage.

Responsibilities

• Provide medical consultation for claims regarding Guarantee Letter or reimbursement disputes.
• Monitor and follow up on complex cases to limit unwarranted extensions of hospital stay.
• Oversee fraud detection and prevention to minimize billing wastages.

Skills

Sound medical knowledge

Strong business acumen

Analytical skills

Negotiation skills

Public relations skills

Education

Licensed practicing Medical Doctor (MBBS/MD)

Postgraduate qualification in occupational health or family medicine

Job description

Manager, Medical Advisor & Case Management

To provide medical consultation and opinion in regard to claims pertinent to Guarantee Letter (GL) or Reimbursement / medical claim disputes or appeals / investigations / underwriting, and to ensure effective implementation of case management intervention in order to efficiently reduce or contain healthcare cost, without compromising healthcare quality and needs, in addition to development of quality assurance programmes or other relevant initiatives for organization.

• Medical advisory lead within and beyond operations divisions. To provide medical insights to various divisions within the company such as Medical Claims, Network Management, Call Centre, Customer Services, Product Management & Pricing, Strategic Business Development etc.
• To monitor and follow up with complex cases that require prolonged stay or due for discharge based on the length of stay planned / benchmarked; with the objective of limiting unwarranted extension of stay without compromising the care quality and to evaluate / approve for Top Up GL that fulfills criteria set within the proposed benchmark.
• To provide medical consultation and opinion in regard to admissibility and necessity of medical claims, fulfilment of policy contract definition in medical claims, investigation and underwriting decisions, as well as ad-hoc medical consultation and opinion in medical related queries.
• To communicate with panel specialists via call conference or virtual meetings regarding Professional Fee Queries and address overcharging issues or any issues on specialist’s fees to appropriate parties such as hospital management / hospital fee committee and Ministry of Health (MOH), medical councils, LIAM / PIAM as and when required, in accordance with the PHFSA Fee Schedule and reasonable & customary charges (R&C) guides.
• To develop / coach claim assessors through regular medical trainings and development / revision of internal claims guidelines to enhance their medical knowledge and competency in claim assessment to deliver services in keeping with the standards set.
• To involve in projects and/or initiatives for department / division process improvement.
• To conduct quality assurance checking on medical claims; to vet through periodical service report and follow up with relevant parties for remedial actions and its implementation as and when required.
• Take accountability in considering business and regulatory compliance risks and take appropriate steps to mitigate the risks.
• Maintain awareness of industry trends on regulatory compliance, emerging threats and technologies in order to understand the risk and better safeguard the company’s interest.
• Highlight any potential concerns / risks and proactively share the best risk management practices.
• In charge of fraud, waste and abuse (FWA) detection, resolution and prevention to minimize billing wastages by reviewing and analyzing trends and emerging patterns in hospital and doctors’ charges, implementing controls on claims overutilization.
• Qualifications: Licensed practicing Medical Doctor (MBBS / MD) in good standing in medical community, preferably with clinical experience/ specialty in internal medicine, paediatrics, and surgical based. Postgraduate qualification in occupational health, family medicine, or any relevant field would be an added advantage. Experience in a public/ private hospital is essential. Experience in analysis, fraud detection is an added advantage.
• Working Experience: Minimum 5 years working experience in healthcare and/or insurance.
• Key Skills: Sound medical knowledge; knowledge of healthcare billing and medical terminology; strong business acumen with communication, analytical, problem solving, documentation and organization skills; strong negotiation and public relation skills.
• Key Knowledge: Knowledge in medical terminology, clinical knowledge; Proficiency in current healthcare delivery systems and hospital, patient management and billing system; insurance product and contractual wordings knowledge.
• Key Competencies: Customer service, product knowledge, medical knowledge, information gathering and analysis, policy interpretation and application, processes, procedures and policies.
• Demonstrate alignment with the organisation’s core values through expected behaviours.
• High level of integrity, take accountability of work and good attitude over teamwork.
• Take initiative to improve current state of circumstances and adaptable to embrace new changes.