Healthcare Network Operations Senior Specialist (Chuyên viên Cấp cao Nghiệp vụ Hệ thống CSYT)

Prudential's purpose is to be partners for every life and protectors for every future.

The incumbent is responsible for supporting the governance and quality management of empaneled medical providers, ensuring alignment with company policies and medical provider management standards.

Job Description

1. Network Operations & Coordination

• Execute day-to-day operations of hospital and clinic network within the Direct Billing ecosystem, ensuring adherence to claims submission processes, workflows, and service standards.
• Act as the operational focal point for medical providers, supporting communication, issue resolution, and process alignment.
• Support provider onboarding activities, including validation of operational readiness and compliance with requirements.

2. Provider Performance & Claims Coordination

• Monitor provider performance indicators (e.g. TAT, accuracy, rejection/dispute cases) and escalate operational gaps or issues.
• Coordinate closely with Claims teams to ensure efficient end-to-end claims processing and resolve provider-related issues.
• Identify discrepancies, inefficiencies, or unusual patterns, including potential fraud or abuse, for further review.

3. Quality Assurance & Operational Improvement

• Support provider review, audit, or site visit activities, and follow up on corrective actions to improve service quality.
• Contribute to process standardization and workflow optimization initiatives.
• Support digital and automation initiatives related to Direct Billing operations and claims workflows.

Job Accountability

• The incumbent is responsible for supporting the development and implementation of the medical provider empaneling process, including identifying potential providers and coordinating negotiations for service agreements.

Job Requirements

a. Qualification

• Degree in Insurance, Medical or Business Management.

b. Experience

• Experience working in medical providers or continuously with medical providers.
• Experience working in Network Management/Hospital Management positions at insurance companies.
• Experience working related to healthcare products at insurance companies.

c. Knowledge, Skills & Attribute

• Insurance/hospital or medical/nursing background
• Possess knowledge on Life Insurance claims processing
• Computer literate and familiar with MS Excel, MS Word & MS PowerPoint
• Innovative/Creative
• Self-assured and results oriented