Claims Assessor

FULLERTON HEALTHCARE GROUP PTE. LIMITED; Singapore; Presencial; SGD 42.000 - 56.000; Jornada completa

Descripción de la vacante

FULLERTON HEALTHCARE GROUP PTE. LIMITED is seeking a skilled Claims Assessor in Singapore to evaluate inpatient and outpatient medical claims for group insurance policies.

You will review claims for accuracy, ensure adherence to policy terms, and handle CPF rejections with root-cause analysis. Daily processing, audits, and collaboration with providers and policyholders are essential to maintain service levels.

Formación

• Diploma or higher educational qualification.
• Strong knowledge of health insurance policies and claims processes.
• At least 1 year of experience in claims assessment.
• Ability to interpret medical reports and understand medical terminology.
• Excellent analytical and decision-making skills.
• Meticulous and high accuracy in claims processing.
• Good communication skills, both written and verbal.

Responsabilidades

• Review inpatient and outpatient claims for accuracy and compliance.
• Ensure claims processing aligns with policy coverage and guidelines.
• Perform daily claims processing and checks to meet turnaround times.
• Analyze CPF rejections and identify root causes for corrective actions.
• Conduct weekly appeal audits to validate decisions and improve processes.
• Investigate complex cases and client complaints with timely resolutions.
• Liaise with healthcare providers, policyholders, and internal stakeholders for required information.
• Flag potentially fraudulent claims and escalate according to protocols.
• Document claims assessments, decisions, and audits for reporting and audits.

Conocimientos

Health insurance knowledge

Claims assessment experience

Analytical skills

Medical terminology

Communication skills

Educación

Diploma or higher

Descripción del empleo

Role Overview

As a Claims Assessor, you will be responsible for evaluating medical claims, particularly hospitalization and clinical claims, for group insurance policies. This role ensures claims are processed efficiently, accurately, and in a timely manner, while maintaining excellent service levels and confidentiality.

Key Responsibilities

• Review and assess inpatient (IP) and outpatient (OP) claims-including medical, surgical, and hospital cases-for accuracy, completeness, and compliance with policy requirements.
• Ensure claims are processed in accordance with policy coverage, terms and conditions, regulatory standards, and internal guidelines.
• Carry out daily claims processing and checks, ensuring timely settlement within agreed turnaround times (TAT).
• Analyse CPF rejections by identifying root causes, resolving discrepancies, and implementing corrective actions to minimise recurrence.
• Perform daily second-level checks to maintain quality, consistency, and compliance in claims handling.
• Conduct weekly appeal audits to validate decisions, ensure proper case handling, and support continuous improvement.
• Investigate complex cases and client complaints, providing effective and timely resolutions while maintaining service quality.
• Liaise with healthcare providers, policyholders, and internal stakeholders to obtain required information for accurate claims evaluation.
• Identify and flag potentially fraudulent claims or irregular patterns, escalating cases according to established protocols.
• Collaborate with team members and supervisors to improve processes, enhance efficiency, and support quality initiatives.
• Maintain accurate and complete documentation of claims assessments, decisions, audits, and reviews for reporting and audit readiness.

Key Requirements

• Diploma or higher educational qualification.
• Strong knowledge of health insurance policies and claims processes.
• At least 1 year of experience in claims assessment, preferably in health or insurance setting.
• Ability to interpret medical reports and understand medical terminology.
• Excellent analytical and decision-making skills.
• Meticulous and high accuracy in claims processing.
• Good communication skills, both written and verbal.