Manager, Medical Advisor & Case Management

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

Job summary

A leading insurance provider seeks a Manager, Medical Advisor to oversee medical consultations and claims management. The role involves ensuring quality case management, developing training for assessors, and maintaining compliance with healthcare standards. Candidates should be licensed medical doctors with significant experience in healthcare or insurance.

Qualifications

• Licensed Medical Doctor in good standing with clinical experience.
• Minimum 5 years of healthcare and/or insurance experience.

Responsibilities

• Provide medical consultation on claims and implement case management.
• Monitor complex cases and evaluate claims for necessity.
• Conduct quality assurance checks on medical claims.

Skills

Medical knowledge

Healthcare billing

Analytical skills

Problem-solving

Negotiation skills

Education

Licensed Medical Doctor (MBBS / MD)

Postgraduate qualifications in occupational health or family medicine

Job description

Job Description - Manager, Medical Advisor & Case Management (250000C9)

Job Number: 250000C9

About the Job

This role involves providing medical consultation and opinions regarding claims related to Guarantee Letters (GL), reimbursement, medical claim disputes, appeals, investigations, and underwriting. The goal is to implement effective case management interventions to reduce or contain healthcare costs without compromising quality and patient needs. The role also includes developing quality assurance programs and other initiatives.

The Medical Advisor will lead within and beyond operations divisions, providing medical insights to departments such as Medical Claims, Network Management, Call Centre, Customer Services, Product Management & Pricing, and Strategic Business Development.

1. Monitor and follow up on complex cases requiring prolonged stays or discharge planning, aiming to limit unnecessary extensions without compromising care quality. Evaluate and approve Top Up GLs based on benchmarks.
2. Provide medical opinions on the admissibility and necessity of claims, policy fulfillment, investigations, underwriting, and ad-hoc medical queries.
3. Communicate with panel specialists regarding professional fee queries and overcharging issues, coordinating with hospital management, medical councils, and regulatory bodies as needed, following relevant fee schedules and guidelines.
4. Develop and coach claim assessors through training and guideline revisions to enhance their medical assessment skills.
5. Participate in projects aimed at process improvement within the department/division.
6. Conduct quality assurance checks on medical claims, review service reports, and follow up on remedial actions.
7. Work with stakeholders to promote a culture aligned with the organization’s core values and ensure compliance with business and regulatory standards.
8. Stay informed on industry trends, regulations, and emerging threats to better safeguard the company's interests.
9. Identify and address potential risks, sharing best practices for risk management.
10. Oversee fraud, waste, and abuse detection and prevention efforts, analyzing trends to minimize billing wastages.

Qualifications and Experience

• Licensed Medical Doctor (MBBS / MD) in good standing, preferably with clinical experience in internal medicine, pediatrics, or surgery. Postgraduate qualifications in occupational health or family medicine are advantageous. Experience in hospitals is essential; experience in analysis and fraud detection is a plus.
• Minimum 5 years of healthcare and/or insurance experience.

Key Skills and Knowledge

• Strong medical knowledge, familiarity with healthcare billing, and medical terminology.
• Business acumen, communication, analytical, problem-solving, documentation, and organizational skills.
• Negotiation and public relations skills.
• Knowledge of clinical practices, healthcare delivery systems, hospital and billing systems, and insurance products.

Core Competencies

• Customer service orientation, product and medical knowledge, analytical skills, policy interpretation, and adherence to procedures and policies.
• Alignment with organizational values, integrity, accountability, initiative, and adaptability.

About Us

Founded in 1908, Great Eastern is a leading insurance provider in Singapore and Malaysia, with assets over S$100 billion and more than 16 million policyholders. It operates through various channels and has subsidiaries in Indonesia and Brunei. Recognized for its financial strength, it is part of OCBC, one of the most highly-rated banks globally.

Note: We do not accept unsolicited resumes from recruitment agencies and will not be responsible for related fees.