Main Responsibilities:

Claims Adjudication & Compliance Control

• -        Assess and process outpatient, MD (Médecin à Domicile), optical, and reimbursement claims.
• -        Verify eligibility, benefit limits, waiting periods, and underwriting conditions.
• -        Capture claims accurately in the system within SLA timelines.
• -        Return incomplete claims and request missing documentation.
• -        Maintain daily claims tracking and log records.

Productivity & SLA Compliance

• -        Process a minimum of 30–50 claims per day.
• -        Avoid backlog accumulation and ensure structured daily workflow.
• -        Ensure compliance with internal turnaround time standards

Quality Control & Risk Management

• -        Apply internal checklist before approval or rejection.
• -        Maintain error rate below 3% and prevent financial leakage.
• -        Identify and escalate suspicious or potentially fraudulent claims.
• -        Maintain audit-ready documentation and strict confidentiality

Optical & Inpatient Support

• -        Issue optical authorisations upon eligibility verification.
• -        Prepare Guarantees of Payment (GOP) for clinics once approved.
• -        Prepare inpatient checklist for Medical Officer review.
• -        Provide underwriting and claims history information for admissions.

Member, Broker & Provider Engagement

• -        Respond to emails within the same working day and clear backlog daily.
• -        Answer member calls and provide benefit clarifications professionally.
• -        Liaise with providers and brokers to resolve documentation discrepancies.
• -        Escalate complex cases to Team Leader when necessary.

Financial & Payment Support

• -        Extract payment resumes and submits to Finance for settlement.
• -        Validate provider invoices prior to payment submission.

Emergency & Operational Support

• -        Participate in after-hours emergency hotline on rotational basis.
• -        Coordinate urgent inpatient admissions and approvals.

Academic Qualifications:

• Minimum HSC or equivalent qualification.

Functional skills:

• Answer customers in a friendly, professional manner and attends to e-mail inquiries in a timely manner.
• Have good communication and interpersonal skills.
• Team Spirit: Helps the team in case of backlog.
• Ensure compliance by following company policies, procedures, and guidelines.

Key competencies:

• Attentive to details
• Fast processor with objectives to meet Turnaround time as per SLAs.
• Accuracy in data capturing.
• Continuous Innovation
• Ownership & Commitment