Sr. Specialist - Claim Reimbursement (direct)

Nice to know

Support Claims Reimbursement Team. Also, handle the documents of claims assessment, Support to monitors the pending cases or back log.

Your Day at Allianz Ayudhya

1) Claims Reimbursement

• Support team to investigate and make decisions for claims assessment by covering the actions below:
• Approve the payment based on authorization.
• Perform rejection of claims reimbursement
• Require the additional information
• Issue memo into the system for administration in performing next steps
• Submit for further investigation
• Request the hospital records from hospital
• Continuously monitor and make decision for the pending cases of Claims Reimbursement, or back log
• Consolidate the complex cases and prepare for Claim Committee and COO/ CEO according to the authorization

2) Hospital assessment Claims (OPD cashless)

• Handling the OPD cashless claims from the hospital
• Perform investigation and make decision for OPD cashless claims received in the system
• Approve for the payment base on authorization
• Perform rejection of fax claims received
• Require the additional information
• Issue memo into the system for administration in performing next steps
• Submit for further investigation
• Request the hospital records from hospital
• Continuously monitor and make decisions for the pending cases of OPD cashless Claims Hospital, or back log
• Manage the complex cases which require Claim Committee Decision, and present to Claim Committee and COO/ CEO according to the authorization
• Handle claim approvals, ensuring accuracy, timeliness, and adherence to service level agreements (SLAs).

Must Have

• Degree in business administration, Nursing, Business Sciences (Medical Technology) or related field.
• Minimum 5 years of experience in Claims Assessor or other related fields in insurance industry.
• Experience/knowledge in nursing, medical, claim insurance related topics, regulation, policy, guideline

Nice to Have

• Accuracy concern & detail orientation
• Experience in using claims/CRM systems
• Ability to prioritize claim related functions
• Knowledge of MS Office, Excel, PowerPoint or data software Power BI
• Any AI-future skills e.g., ChatGPT, or CoPilot365, will be advantage