PSO Claims Representative (APAC)

Cigna Health and Life Insurance Company; Kuala Lumpur; On-site; MYR 36,000 - 60,000; Full time

Job summary

Cigna Health and Life Insurance Company in Kuala Lumpur is seeking a claims processing professional to support provider inquiries and medical coverage determinations. You will process claims, verify eligibility, and maintain pre-authorizations in line with policy terms.

The role requires 1–2 years of relevant experience, strong organizational skills, and proficiency in Microsoft Office. Shift-based work is possible to meet service demands.

Qualifications

• Experience handling medical claims and provider inquiries.
• Strong data entry and organizational skills.
• Ability to meet processing targets and SLA.

Responsibilities

• Process claims from providers in line with policy coverage and medical necessity.
• Assess eligibility and medical necessity within policy boundaries.
• Maintain pre-authorizations and claims processing per terms and policies.
• Monitor SLA, quality, and KPI targets for claims and pre-approvals.
• Collaborate with cross-functional teams to resolve queries and support operational goals.

Skills

Claims processing

Data entry

Customer service

Microsoft Office

Tools

Microsoft Office

CRM systems

Job description

JOB PURPOSE

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 providers. 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 mind the 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

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. 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. Doing something meaningful starts with a simple decision, a commitment to changing lives. At The Cigna Group, we’re dedicated to improving the health and vitality of those we serve. Through our divisions Cigna Healthcare and Evernorth Health Services, we are committed to enhancing the lives of our clients, customers and patients. Join us in driving growth and improving lives.