Training, Case Management & Ops SOP Governance, Analyst

AIA Hong Kong; Kuala Lumpur; On-site; MYR 60,000 - 75,000; Full time

Job summary

A leading insurance company in Kuala Lumpur is seeking an experienced professional for health claims management. You will conduct audits, manage policy cases, and implement process improvements. The ideal candidate has over 5 years of experience in health claims or clinical roles, with strong analytical and communication skills. Join us as we strive to improve lives and contribute to the community.

Qualifications

• 5+ years of experience in health claims management or clinical advisory roles.
• Experience in audit or quality assurance is preferred.
• Knowledge of insurance claims adjudication and MOH guidelines.

Responsibilities

• Conduct audits and manage complex policy cases to prevent fraud.
• Implement process improvements within insurance operations.
• Mentor and guide team members in decision-making.

Skills

Analytical skills

Audit skills

Communication

Stakeholder management

Proficiency in MS Office

Education

Bachelor’s degree in health sciences or equivalent

Tools

Claims platforms

Report automation tools

Job description

At AIA we’ve started an exciting movement to create a healthier, more sustainable future for everyone.

It’s about finding new ways to not only better people’s lives, but to better the communities and environments we live in. Encompassing our ambition of helping a billion people live Healthier, Longer, Better Lives by 2030.

And to get there, we need ambitious people who believe in playing an important part in shaping that future. People seeking unmatched career and personal growth opportunities, who are driven to work with, and learn from some of the most inspiring and supportive leaders in the business.

Sound like you? Then read on.

About the Role

Responsible for determining operational excellence and customer satisfaction by empowering assessors through continuous training, reducing operational costs, ensuring consistent in validity and authorizing settlement of medical health. Responsible for handling complex policy cases which require special investigative skills or significant involvement and collaboration from different stakeholders to follow through together with MOH directives while fostering a culture of compliance, efficiency, and integrity.

Roles & Responsiblities:

• To conduct Amount Under clarification (AUC) and case management, regular audits, and handle critical issues to identify Fraud, Waste and Abuse
• To ensure claim ad judication is in accordance with reasonable and customary charges and to review trending of doctors / members / agents that may or may not be in the watch list.
• To analyse and assess significant underwriting and claim cases with the aim of preventing fraud.
• To provide the ability to outline and implement process improvement strategies and cost-saving measures within insurance operations.
• To coordinate activities of expert resources in relevant functions / departments in the effort to resolve the case and recommend operational improvements as appropriate
• To interpret the 13th Schedule, Ministry of Health (MOH) letters, and assessment of reasonable and customary charges and align with medical procedures and costs.
• To provide basic Medical Advisory for claims team members on disputed charges and appeal.
• To respond to inquiries of a technical or complex nature through case management.
• To conduct robust medical training aligned with technical aspects of claims processing.
• To mentor/coach and guide the TLs and assessors in robust decision making.
• May work with third parties and government authorities to support external investigation and prosecution of fraudulent cases

Minimum Job Requirements:

• Education: Bachelor’s degree in health sciences, Life Sciences, Healthcare Management, Nursing or equivalent. A medical degree is advantageous but not mandatory.
• Experience: Minimum 5 years in health claims management, case management, or clinical advisory roles. Prior audit or quality assurance experience preferred.
• Certifications/Licenses: Any industry-related medical or healthcare certification (e.g., claims adjudication, healthcare audit, or insurance-specific certifications).
• Strong analytical and audit skills.
• Knowledge of insurance claims adjudication, MOH guidelines, and clinical coding.
• Excellent communication and stakeholder management.
• High proficiency in MS Office, claims platforms, and report automation tools

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. You are responsible for ensuring that the information you submit is accurate and up-to-date.