Job Purpose

Responsible for overseeing the daily operations of team. This role ensures that all fraud detection activities are conducted efficiently, accurately, and in compliance with regulatory requirements

Key Responsibilities

• Review claims history for all health riders and AI before due date, 30 days in advance and consider non-renewal or copayment based on the review and ensure timely and accurate processing claims for decision-making
• Process voiding policies upon discovering material misrepresentation or non-disclosure and ensure this process is completed within 30 days of identifying the issue.
• Maintain through documentation of the voiding process and reasons for policy voidance.
• Collect and analyze data on non- renewal and voided policies
• Highlight trends, insights, and recommendation based on the collected data
• Conduct through investigations of suspicious claims, including reviewing documentation and coordinating with the relevant stakeholders
• Prepare detailed reports on findings and actions taken
• Present reports and recommendations to senior management as required
• Provide insights and recommendations for improving fraud detection strategies
• Assist in developing and implementing rules and guidelines to improve the detection and prevention of fraudulent claims
• Gather, analyze, and interpret relevant data to inform decision-making processes, ensuring that decisions are based on accurate and comprehensive information.
• Monitoring the impact of rule changes on STP rates and making further adjustments as needed

Qualifications

• Bachelor or Master degree with medical background
• The Professional Nursing and Midwifery License or another related Medical License LOMA or ICA is a plus.
• At least 5-10 years experienced in health claims.
• Experience in dealing with hospital, reinsurer, complaint clarification and negotiation at OIC and other external firms is required.
• Experience of the co–project / team member or system enhancement