Specialist-Claims (Corporate Solutions)

AIA Shared Services; Cyberjaya; On-site; MYR 60,000 - 90,000; Full time

Job summary

Join AIA Shared Services as a Claims Assessor to process complex inpatient and outpatient claims for Group Policyholders, applying strong technical judgment, policy interpretation, and data driven insights to ensure fair claim outcomes and effective risk management.

Leverage digital tools, rules engines, and automation outputs while exercising human judgment for cases requiring interpretation or escalation, and to support continuous improvement of claims processes.

Qualifications

• Minimum 3 years of relevant experience in handling minor medical claims.
• Strong knowledge of claims assessment, including policy interpretation, exclusions, and medical terminology.
• Analytical mindset to interpret data, trends, and fraud indicators.
• Strong problem‑solving and critical‑thinking skills for handling exceptions and escalations.
• Willingness to adopt new systems, automation, and analytics tools.

Responsibilities

• Process complex inpatient and outpatient claims for Group Policyholders.
• Analyze medical reports, invoices, and documents to validate eligibility.
• Identify, investigate, and escalate potential fraud, abuse, or leakage risks.
• Ensure claims are processed within defined turnaround time, productivity and quality benchmarks.
• Provide technical guidance and knowledge sharing to junior assessors.
• Collaborate with internal and external stakeholders to resolve escalations and support outcomes.
• Prepare clear, professional correspondence to claimants and providers and ensure timely follow‑ups.

Skills

Claims assessment

Policy interpretation

Dispute resolution

Data analysis

Fraud detection

Communication

Job description

About the Role

To process complex inpatient and outpatient claims for Group Policyholders and apply strong technical judgment, digital tools, and data driven insights to ensure fair claim outcomes, effective risk and fraud identification, and continuous improvement of claims processes.

Independently assess complex claims by applying strong technical judgment, policy interpretation, and medical understanding to ensure fair and accurate claim outcomes.

Leverage digital tools, rules engines, and available automation outputs to enhance assessment efficiency, while exercising human judgment for cases requiring interpretation, exceptions, or escalation.

Analyze medical reports, invoices, and supporting documentation to validate claim eligibility, identify inconsistencies, and determine appropriate claim decisions in line with policy terms and exclusions.

Ensure claims are processed within defined turnaround time (TAT), productivity, and quality benchmarks, balancing speed with accuracy and service excellence.

Identify, investigate, and escalate potential fraud, abuse, or leakage risks, working closely with the Fraud Investigation Unit and relevant stakeholders to support effective risk mitigation.

Manage claims requiring additional information by preparing clear, professional, and compliant correspondence to claimants, healthcare providers, and third parties, ensuring timely follow‑ups and resolution.

Resolve payment discrepancies and suspense items through coordination with Finance, customers, and internal teams to ensure accurate and timely settlement.

Provide technical guidance, coaching, and knowledge sharing to junior assessors, supporting consistent decision‑making, quality improvement, and team capability uplift.

Identify opportunities for process improvement, simplification, and automation, contributing ideas and feedback to enhance claims accuracy, efficiency, and customer experience.

Collaborate effectively with internal and external stakeholders (e.g. business partners, hospitals, service providers) to resolve escalations and support positive customer outcomes.

Perform additional duties as required to support operational resilience, service continuity, and evolving business needs.

Requirements

Minimum 3 years of relevant experience in handling minor medical claims

Strong technical knowledge of claims assessment, including policy interpretation, exclusions, medical terminology, and dispute resolution, with consistent application of judgment and controls.

Analytical mindset with the ability to interpret data, trends, and exception indicators, including fraud flags, anomaly alerts, and quality findings to support sound, risk‑based decision‑making.

Strong problem‑solving and critical‑thinking skills, particularly in handling exceptions, escalations and non‑straight‑through processing cases.

High level of attention to detail and follow‑through, ensuring completeness, accuracy, and timely closure of claims and related correspondence.

Effective communication skills, both written and verbal, with the ability to explain claim decisions clearly and professionally to internal and external stakeholders through digital channels.

Willingness and ability to adapt to change, including adoption of new systems, automation, analytics tools, and evolving claims practices.

Demonstrate commitment to continuous learning, skill development and participation in process improvement initiatives.

Build a career with us as we help our customers and the community live Healthier, Longer, Better Lives.

You must provide all requested information, including Personal Data, to be considered for this career opportunity. Failure to provide such information may influence the processing and outcome of your application.

Better starts with people who reimagine what is possible and turn ideas into meaningful action. At AIA, you will contribute in your own way, help shape outcomes that matter and collaborate with colleagues across disciplines, teams, markets and levels.

We will support you to broaden your perspective, strengthen your capabilities and grow your impact. Together, we challenge assumptions, learn from one another and find better ways forward. Bring your ambition, experience and ideas to AIA, and help shape what “better” looks like.

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