Claim Assessment Manager (Quản lý Thẩm định Bồi thường)

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

The Claim Assessment Manager (Quản lý Thẩm định Bồi thường) is responsible for leading and governing the end-to-end healthcare claims assessment function, ensuring alignment with company policies, operational standards, and regulatory requirements.

Key Responsibilities:

• Lead and oversee daily healthcare claims operations, ensuring timely adjudication in compliance with Operating Manual, SLA, and quality standards.
• Govern claims assessment processes across reimbursement and direct billing, including complex case review, escalation handling, and decision oversight.
• Ensure effective implementation of quality assurance and audit frameworks (internal audit, QA, SOX/GwIA), maintaining high standards of claims accuracy and compliance.
• Act as the key liaison between Claims and cross-functional stakeholders (TPA, medical providers, Product, System, Risk, Finance) to resolve operational issues and improve claims processes.
• Drive cost control and risk management initiatives, including monitoring fraud, waste, and abuse (FWA), ensuring medical necessity and appropriate treatment evaluation.
• Oversee claims system utilization and improvement, ensuring accurate data capture, system updates, and alignment with automation initiatives.
• Lead communication and engagement with external stakeholders, including hospitals and TPA, to manage claims-related matters, disputes, and service quality issues.
• Drive continuous improvement projects to enhance productivity, turnaround time, and customer experience in claims servicing.
• Manage team performance, including resource planning, training, coaching, and performance monitoring to ensure consistent delivery of service excellence.
• Prepare and review reports on claims performance, quality metrics, and risk indicators for management decision-making.

Requirements:

• Degree in Biomedical Science, Allied Health, Economics, Business Administrative, Business Management, or related fields.
• Preferably experience in healthcare and/or claims, i.e., customer service, healthcare claims department, or hospital environment.
• Working at an insurance company or banking at a managerial level for at least 5 years.
• Insurance/Legal/Health management and project management skills.
• Possess knowledge of life insurance claims processing.
• Computer literate and familiar with MS Excel, MS Word, and MS PowerPoint.
• Self-assured and results-oriented.