Claims Manager

Location : Kuala Lumpur Malaysia

Employment Type : Full-Time

Industry : Healthcare / Insurance / Third-Party Administration (TPA)

About the Role

We are seeking a highly skilled and detail-oriented Claims Manager to lead and oversee our medical and dental claims operations. The ideal candidate will bring deep expertise in Third-Party Administration (TPA), hold SCI or CGI certification, and possess strong knowledge of rules-based adjudication and medical coding standards (ICD, CPT, HCPCS).

This role is critical in ensuring accurate, compliant, and timely claims processing while driving operational excellence and supporting clinical integrity across our provider network.

Key Responsibilities

• Manage end-to-end claims adjudication processes for inpatient, outpatient, emergency, and dental services
• Ensure claims are reviewed based on medical necessity, benefit coverage, member eligibility, and policy exclusions
• Apply rules-based logic and coding standards to validate claims accuracy (ICD-10, CPT, HCPCS)
• Collaborate with medical review teams to resolve complex or questionable claims
• Monitor claims turnaround time, accuracy metrics, and compliance with SLAs
• Lead fraud detection and abuse prevention efforts in coordination with compliance and clinical teams
• Liaise with finance for timely liquidation and reconciliation of processed claims
• Maintain documentation workflows and ensure proper issuance of Explanation of Benefits (EOBs)
• Provide insights and recommendations for process improvement and automation initiatives
• Participate in audits, client reviews, and regulatory reporting as needed

Qualifications

What We Offer

Ready to make an impact? Apply now and help us deliver accurate, efficient, and compassionate claims services to our members.

Job Type : Full-time

Pay : From RM7,000.00 per month

Benefits :

License / Certification :

Work Location : In person