Utilization Review Nurse

About the Company

Krungthai-AXA Life Insurance Public Company Limited is a life insurance company formed by a partnership between Krungthai Bank PCL. and the AXA Group. The company is a fast-growing life insurer with a focus on financial protection and asset management.

Responsibilities

• Perform daily concurrent review of patients' clinical information from the hospital network to ensure appropriateness of care in accordance with policy terms and conditions.
• Review medical records to identify errors, missed diagnoses, unnecessary investigations or treatments.
• Coordinate patient discharge planning with UR/UM physician to ensure appropriate length of stay and make discharge decisions based on received clinical information.
• Seek consultation from appropriate disciplines/departments as required to expedite claim decisions and facilitate timely and accurate communication before discharge.
• Refer case issues to team advisor(s) and monitor until resolution.
• Prepare monthly Utilization Management and cost-savings reports for assigned area.
• Monitor claim TAT to ensure cases are completed within SLA.
• Deliver service with a strong focus on customer satisfaction and build strong relationships with hospitals to support a smooth cashless claim journey.
• Support peers in holistic health claim management and ensure correctness of claim data capturing.
• Assist in managing team daily performance and participate in process improvement initiatives, revisiting current processes to identify quick-win solutions.
• Support quality and cost-efficiency controls, internal control tools and internal audit programs to determine claim authority and performance evaluation.
• Help develop work instructions, guidelines for hospitals and claim SOPs; establish checks and balances and provide stakeholder feedback related to performance.
• Report significant incidents with immediate actions, short-term solutions and preventive actions; provide regular and ad hoc reports.
• Contribute to people development: develop multiple skills, provide regular feedback, monitor and encourage self-learning, and assist in training CCC and distributors.

Qualifications

• Bachelor's degree in Nursing.
• At least 2–3 years' experience as a UR Nurse or nurse in ward/ICU in hospital.
• At least 1 year of working experience in Life or Non-Life Insurance and Health Claims preferred.
• Previous training and demonstrated competence in negotiation, quality assurance and case management outcomes.
• Capable of communicating in both written and spoken English.
• Able to negotiate and handle issues with external and internal parties.

Benefits

• Employee and Family Health Insurance.
• Life and Accident Insurance.
• Hybrid working and flexible working hours.
• Annual leave & birthday leave.
• Salary increment & bonus.
• Digital learning / self-learning organization.
• Annual health check-up.
• Provident fund.