Manager, Medical Advisor & Case Management

Great Eastern Life; Kuala Lumpur; On-site; MYR 100,000 - 140,000; Full time

Job summary

A leading company in the insurance sector is seeking a Manager for Medical Advisor & Case Management. The role involves providing medical insights and managing complex healthcare claims, ensuring compliance and quality assurance. Candidates should hold a medical degree and have significant experience in the healthcare or insurance industries.

Qualifications

• Minimum 5 years experience in healthcare and/or insurance.
• Clinical experience/specialty in internal medicine, paediatrics, or surgical based preferred.
• Experience with fraud detection is advantageous.

Responsibilities

• Provide medical consultation regarding claims and quality assurance.
• Monitor complex cases and approve Top Up GL based on benchmarks.
• Communicate with specialists on fee queries and address overcharging issues.

Skills

Sound medical knowledge

Strong business acumen

Communication skills

Analytical skills

Problem solving skills

Documentation skills

Organization skills

Negotiation skills

Public relation skills

Education

Licensed practicing Medical Doctor (MBBS / MD)

Postgraduate qualification in relevant field

Job description

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

Manager, Medical Advisor & Case Management (

Job Number:

250000C9 )

About the Job

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 in order 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.
• As part of the leadership team, work with key stakeholders to proactively shape the organisation’s culture and conduct environment that is aligned to the organization’s Core Values.
• Takes accountability in considering business and regulatory compliance risks and takes appropriate steps to mitigate the risks.
• Maintains awareness of industry trends on regulatory compliance, emerging threats and technologies in order to understand the risk and better safeguard the company’s interest.
• Highlights any potential concerns / risks and proactively shares 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.

We are looking for people who

• 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.
• Demonstrates alignment with the organisation’s core values through expected behaviours
• High level of integrity, takes accountability of work and good attitude over teamwork.
• Takes initiative to improve current state of circumstances and adaptable to embrace new
  changes.

Who we are

Founded in 1908, Great Eastern is a well-established market leader and trusted brand in Singapore and Malaysia. With over S$100 billion in assets and more than 16 million policyholders, including 12.5 million from government schemes, it provides insurance solutions to customers through three successful distribution channels – a tied agency force, bancassurance, and financial advisory firm Great Eastern Financial Advisers. The Group also operates in Indonesia and Brunei. The Great Eastern Life Assurance Company Limited and Great Eastern General Insurance Limited have been assigned the financial strength and counterparty credit ratings of "AA-" by S&P Global Ratings since 2010, one of the highest among Asian life insurance companies. Great Eastern's asset management subsidiary, Lion Global Investors Limited, is one of the leading asset management companies in Southeast Asia. Great Eastern is a subsidiary of OCBC, the longest established Singapore bank, formed in 1932. It is the second largest financial services group in Southeast Asia by assets and one of the world’s most highly-rated banks, with an Aa1 rating from Moody’s and AA- by both Fitch and S&P. Recognised for its financial strength and stability, OCBC is consistently ranked among the World’s Top 50 Safest Banks by Global Finance and has been named Best Managed Bank in Singapore by The Asian Banker.

To all recruitment agencies: Great Eastern does not accept unsolicited agency resumes. Please do not forward resumes to our email or our employees. We will not be responsible for any fees related to unsolicited resumes.

To All Recruitment Agencies Great Eastern does not accept unsolicited agency resumes. Please do not forward resumes to our email or our employees. We will not be responsible for any fees related to unsolicited resumes.