Function: Customer & Information Technology | Department: Customer Office
Type: Individual Contributor
Report to: Manager, Healthcare Claims
Location: Ho Chi Minh
Position no.1: Claim Assessment, Analyst (Direct Billing)
THE OPPORTUNITY:
• Actively contribute at least three creative ideas per quarter to the team to enhance performance and achieve claim cost savings of 10%
• Manage direct billing claims within the Turnaround Time (TAT) of 2 hours for final LOG, 30 minutes for outpatient cases, ensuring a 99% accuracy rate. Collaborate effectively with medical provider staff and proactively engage with medical providers to ensure customers have the best experience and expenses are controlled reasonably.
• Maintain a customer- centric approach throughout the claim process, achieving a customer satisfaction score of 90% or higher.
ROLES AND RESPONSIBILITIES:
Direct Billing handling (60%)
• Collaborate closely with hospital staff to ensure treatment expenses are necessary and appropriate, avoiding unnecessary abuse.
• Perform other responsibilities and duties as periodically assigned to support the company’s business
• Proactively contribute good practices and ideas to the team to improve performance.
• Document patients’ health information, including medical history, examination and test results, and any treatments or procedures provided.
• Prepare proper documentation and, if possible, provide recommendations on cases referred to higher authority levels, the Claim Committee, or re- insurers for decisions.
• Utilize classification software to accurately apply clinical codes in the system for each sub- benefit.
• Thoroughly and promptly assess all direct billing cases, ensuring claims decisions within Claim Authority are based on valid grounds and fully comply with Claim guidelines, policies, and terms and conditions.
• Achieve claims SLA commitments to customers, distribution, and partners.
• Maintain the confidentiality of all patient records.
Reimbursement claim handling (30%)
• As a claim assessor, to be responsible for processing reimbursement claim if assigned by manager.
• Training for newcomers about the healthcare claim practice, medical knowledge if any.
Customer inquiries (10%)
• Handle customer calls regarding claim information outside of regular working hours to ensure clear and accurate information is provided.
Position no.2: Claim Assessment, Analyst (Reimbursement)
THE OPPORTUNITY:
Manage and resolve claims in a fair, efficient, and empathetic manner to:
• Minimize financial risks and protect company’s financial state (A/E) by identifying potential fraud and implementing preventive measures
• Ensure that policyholders receive the appropriate compensation according to the terms and conditions of their insurance policies and ensure to bring the best claim experiences to customer.
ROLES AND RESPONSIBILITIES:
Re- imbursement claim handling (80%)
• Prepare claims letter and to customers and keep agents updated about claims status/ results.
• Providing guideline, advice to team member or make final decision for the borderline cases.
• Managing the entire lifecycle of insurance claims from submission to resolution to ensure claims are processed accurately and timely.
• Ensuring that claims processing adheres to regulatory requirements and claims procedure.
• Evaluating claims based on policy coverage, medical necessity, and contractual agreements.
• Quality Assurance: Monitoring and auditing claim handling processes to maintain accuracy and efficiency including conducting audits, providing feedback to leader, and implementing improvements.
• Customer Service: Addressing inquiries and issues related to claims from healthcare providers, policyholders, and internal stakeholders.
• Provider Relationship: to ensure smooth operations between HC team and providers daily when dealing with direct billing.
• Work with POS team/ actuary/ UW for Policy value calculation.
• Process payment, ensure policy benefit and policy values to be calculated correctly and pay to the right Beneficiary.
• Communicate with customers/ providers to request additional documents.
Direct Billing claim handling (20%)
• Support or handle cashless claim in case of high volume of claims following manager directions.
• Back up assessor, who is responsible for direct billing hotline, in case of her/his absence.
