Head, Technical Review

Job Scope / Position Summary

As the Head of Technical Review, the person must :

• Develop the unit to ensure it achieves the highest possible standard of excellence in all its activities.
• Planning on operation and function of areas involving technical review and fraud for Claims.
• Organizing production of work and workforce i.e. productivity, allocation of resources.
• Monitoring on achievement of plans.
• People development for succession planning and personal career growth and provide guidance, direction, leadership and support to unit members.
• Plan methods and initiatives to improve the efficiency and effectiveness of the Claims Technical Review operations.
• Functional bridge amongst providers as well as internal stakeholders.
• Coordinate and manage regulatory bodies, group and internal audit exercises for Claims Fraud matters.
• Design investigation process and procedures both physically and digitally to identify potential fraud claims and advise management on multi-dimensional impacts.
• Lead the investigation process on potential fraud incidents and cases inclusive but not limited to field investigations / site visit on suspected fraud cases which includes obtaining, reviewing and securing of evidence of case for follow-up and mitigation measures.
• Review and research evidence / documents to analyze the overall trends and patterns of claims and synthesize data into a professional report with recommendations.
• Conduct Claims Review on Closed Files for assigned type of claims and / or line of business.
• Prepare detailed working papers that evidence work performed, issues discovered and recommendations for improvement.
• Brief respective claims managers on the review process including the workflow and the calibration process to support the Review exercise.
• Collaborates with the claims management team in the development of meaningful action plans that detail the tasks, resources and timeframes necessary to improve the claims process.
• Provide recommendation to the claims teams to ensure the prompt and effective delivery of the action plans.

Main Responsibility

(example but not limited to)

Meet Company's Overall Targeted Claims Fraud Figures

Fraud Detection Rate

Fraud Savings

Design, Introduce and Monitor Claims Technical Review function

Identify high risk sector of claims

Produce quarterly monitoring reports

Ensure Smooth Investigation and Review Process with SOP being followed

Customer expectation management for investigation files

Manage system related matter (Frontend and Backend system)

Ensure All Fraud Claims related matters such as communications, system set-ups, processes, reporting etc. are complied within the guidelines and regulation of BNM, PIAM, Group and other relevant regulatory bodies.

Qualification and Experience Requirement