Manager, FWA & Connected Care
Prudential · Kuala Lumpur
Full-timeonsiteseniorHealthcareHealthcare
รายละเอียดงาน / Description
Based in Malaysia, this role offers strategic medical and clinical oversight to strengthen claims governance, combat fraud, waste, and abuse, and drive cost-containment initiatives. The specialist uses clinical judgment to audit complex files, evaluate DRG coding accuracy, and address potential claims leakage. The position also involves leading doctor panel governance, coordinating external medical expert opinions, and training assessors to maintain top-tier claims integrity.
หน้าที่ความรับผิดชอบ / Responsibilities
- Provide clinical expertise for fraud, waste, and abuse (FWA) investigations, identifying irregular billing and clinical inconsistencies.
- Evaluate complex medical claims for coding accuracy, clinical necessity, and valid exceptions to support DRG implementation.
- Partner with hospitals and healthcare providers regarding DRG strategies, tiering, and medical cost containment.
- Oversee doctor panel governance, including audit reviews, monitoring watchlisted practitioners, and enforcing panel standards.
- Coordinate complex claim referrals needing external expert evaluations while adhering to regulatory standards.
- Develop and conduct targeted training programs for claims assessors to strengthen claims decision-making and reduce leakage.
คุณสมบัติ / Qualifications
- Medical degree with practical DRG coding experience.
- At least 10 years of background in the insurance industry with exposure to medical claims assessment and staff training.
- Allied Health, Healthcare, or Business Management qualifications with insurance analysis skills are advantageous.
- Demonstrated experience in clinical evaluation, handling patients, and liaising with healthcare institutions.
- Sound knowledge of customer service relating to life claims or medical insurance.
- Strong track record in medical audit reviews and regulatory compliance.
ทักษะที่ต้องการ / Required skills
- Clinical Evaluation
- DRG Coding
- Fraud Waste Abuse
- Medical Claims Assessment
- Claims Governance
- Medical Auditing
ทักษะเพิ่มเติม / Nice to have
- Insurance Analytics
- Hospital Liaison
- Health Administration
- Staff Training
สวัสดิการ / Benefits
- Continuous learning and career development opportunities
- Collaborative and inclusive workplace culture
- Opportunities to drive meaningful business and community impact