Claim Assessment Senior Specialist (Chuyên viên Cấp cao Dịch vụ Thẩm định Bồi thường)
Prudential · Thành phố Hồ Chí Minh
Full-timeonsiteseniorHealthcareCustomer Service
รายละเอียดงาน / Description
Based in Vietnam, this role involves evaluating healthcare insurance claims across reimbursement and direct billing workflows in line with operating guidelines. The senior specialist reviews complex medical cases, verifies treatment necessity, and ensures timely adjudication while meeting strict quality metrics. Additionally, the position collaborates with internal systems, conducts monthly case audits, and interfaces with healthcare providers to resolve potential discrepancies.
หน้าที่ความรับผิดชอบ / Responsibilities
- Adjudicate daily healthcare claims for reimbursement and direct billing cases following operational guidelines.
- Ensure claim assessments comply with service level agreements and turnaround time benchmarks.
- Document case findings and accurately input decisions across internal claims and third-party portals.
- Review complex cases, assess treatment appropriateness, and detect potential fraud or overutilization.
- Perform monthly quality assurance audits on claim settlements and calculate payable benefits.
- Communicate professionally with medical providers and policyholders to clarify ambiguous claim details.
คุณสมบัติ / Qualifications
- Bachelor's degree in Biomedical Science, Nursing, Allied Health, Biological Sciences, or a related discipline.
- Between 2 and 5 years of experience in healthcare claims, customer service, or a hospital setting.
- Strong understanding of life and health insurance claims adjudication processes.
- Familiarity with medical auditing practices and hospital billing procedures.
- Proficiency in standard office applications including Microsoft Excel, Word, and PowerPoint.
- Solid problem-solving mindset with high attention to detail and results orientation.
ทักษะที่ต้องการ / Required skills
- Claims Adjudication
- Healthcare Claims
- Medical Auditing
- Quality Assurance
- Medical Necessity Assessment
- Microsoft Excel
- Customer Service
- Insurance Operations
ทักษะเพิ่มเติม / Nice to have
- Fraud Waste Abuse Detection
- Life Insurance Knowledge