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About the Role
Responsible for determining the validity and authorising settlement of group health insurance claims
Responsibilities:
Operational Leadership
- Lead the Pre-Assessment team for hospitalization and network claims
- Oversee network management, credit facility services, and shortfall claims
- Ensure operational excellence and regulatory compliance
- Support ad hoc projects
Strategic Development
- Drive the development of a comprehensive healthcare ecosystem aligned with Integrated Health Services (IHS) strategies and Value-Based Healthcare Management
- Lead initiatives in network steerage, utilization management, and fee structure optimization
- Develop clinical guidelines and digital care pathways to ensure consistent and quality care
Analytics & Risk Management
- Investigate early claims and suspicious cases to mitigate fraud and abuse
- Support the Head of Claims in implementing performance metrics and analytics
- Collaborate with stakeholders to enable data-driven decision-making
Stakeholder Engagement
- Strengthen relationships with medical providers, internal teams, and external partners
- Represent the department in cross-functional projects and strategic forums
Requirements:
- Bachelor's degree or above preferrable in healthcare related
- 10 years relevant experience in medical insurance industry with solid managerial experience in medical claims assessment with clinical knowledge
- Professional qualification in FLMI, FLHC, etc. is an advantage.
- Familiar with operation of medical claims and healthcare network providers
- Excellent communication and interpersonal skills
- Strong problem-solving abilities and attention to detail
- Flexible and customer-oriented
- Able to handle multi-task and work in a dynamic fast-paced environment
- Fluent in English and Chinese (Cantonese) both in writing and verbal
- Proficient in MS Office and Chinese Word Processing
Others:
- You are required to obtain relevant license if your job involves in regulated activities
