Assess and adjudicate Life and Medical claims within authority limits in accordance with policy terms and conditions.
Conduct claims investigations where necessary, including reviewing medical evidence, policy documentation, and other relevant information to determine claim validity.
Identify, investigate, and escalate complex claims to the Claims Manager for further review.
Handle escalation enquiries from policyholders, intermediaries, healthcare providers, and internal stakeholders, providing timely and professional resolutions.
Handle appeals, complaints, and disputed claims, ensuring fair and consistent outcomes while maintaining a positive customer experience.
Support continuous improvement initiatives and contribute to enhancing claims processes and customer service standards.
Perform any other duties as assigned by the Claims Manager.
Job Specification
Degree in any discipline.
At least 3 years of experience in Life or Medical Claims handling.
Certification in Health Insurance and General Insurance (BCP, PGI & ComGI) and Life Insurance qualifications.
Ability to review and interpret medical reports, hospital bills, policy contract provisions, and investigation findings.
Excellent communication and interpersonal skills.
Good customer service, complaint-handling, and stakeholder management skills.
Strong analytical, investigative, organizational, and time management skills, with attention to detail.
Job details are sourced from the employer's original posting.
