Medical Advisory, Case & Fraud Management, Specialist

We are looking for a Medical Advisory, Case & Fraud Management, Specialist to join our team in Kuala Lumpur.

Responsible for performing pre-certification; prospective, concurrent, and retrospective review of hospitalization; and to ensure cost containment measures are carried out without compromising on the care quality and service standards.

Key responsibilities:

• Pre-certify cases for issuance of Additional Top Up guarantee letters/ Additional Requests in compliance to Company's requirements and guidelines
• Lead the team and manage rostering / OT and FTE count needed for AGL and ADR
• Ensure guarantee letters are issued accurately and correctly within targeted TAT and with authority assigned
• Achieve team target Savings benchmark
• Performs other responsibilities and duties periodically assigned by supervisor to meet operational and/or other requirements
• Monitor of length of stay, reasonable and customary charges, to ensure there is no abuse in terms of admission and procedures During the adjudication of AGLs and ADR
• Mentor/coach and guide the TLs and assessors in robust decision making
• Ensure all guides and Cost savings initiatives are followed closely by Team leader and assessors
• Participate in outlining Medical training /roll downs according to the needs of the staffs
• Participate in analysis and audits that are pertinent to cost savings across various units in AIA
• Participate in process improvement initiatives pertaining to system enhancement and refining process flow for the team
• Collaborate with various units in AIA in ensuring cost savings and CAR is achieved
• Participate in workshops/seminars and discussion in cost saving initiatives/Fraud, waste and abuse matters
• Lead the Fraud, Waste and Abuse initiatives in conducting analysis