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Senior Manager, Specialist & Quality Audit Management and Advisory

Senior Manager, Specialist & Quality Audit Management and Advisory

AIAAIA Malaysia, Kuala Lumpur, MY
30+ hari lalu
Penerangan pekerjaan

FIND YOUR 'BETTER' AT AIA

If you believe in better, we’d love to hear from you.

About the Role

Position Objective :

  • To lead, coach, supervise and adjudicate work flow and follow up on medical audit cases and the case management team / Top up GL / Additional doctor request and GL appeals.
  • Review and coordinate cases that require the involvement and escalation to providers and internal stakeholders.
  • To provide medical advisory within and beyond AHS
  • To support operations of the AHS
  • To assist in Fraud, Waste and Abuse initiatives.
  • To actively participate in all initiatives related to cost savings & containment exercise
  • To align claims practices across various units in AIA
  • Medical Training for AIA Health Services and stakeholders
  • Active lead in regulator collaborations- MOH / MTA / LIAM
  • To collaborate with all AIA units in digitalization related to medical claims

Roles and Responsibilities :

1. Fraud, Waste & Abuse

  • Oversee and improve upon current methodology for FWA detection, resolution and prevention while driving the TDA program of work – Mapping of codes / Guides translation into AI engines and etc
  • Managing audits within and beyond AIA - Micare& doctors trendings under FWA
  • In charge of analysis on emerging patterns and trends in medical Fraud, Waste and Abuse (FWA) practices
  • Trends doctor’s charges and reviews charging behaviour to establish over utilization – which is supplementary to the provider conversation and trending reports.
  • Collation of reasonable and customary charges within the industry to ensure that charges are within benchmark.
  • Facilitate and implement controls on FWA prevention and minimization of billing wastages.
  • Ensuring recoveries are given within the agreed TAT
  • Close collaboration with the Field investigators to ensure Fraud outcomes are met
  • Active conversation with providers to address Fraud and Waste elements while ensuring strong outcomes are met with the providers

    • 2. Medical advisory lead within and beyond AHS

  • Overseeing medical advisories from AHS and all stakeholders are replied within TAT
  • To review appeals on claims decline with concrete and robust medical literature to support the decision- Within AHS and all complaints related to OFS and BNM
  • Provide medical insights to various divisions within AIA such as Health Claims Management, Network Management and Healthcare Strategy, Corporate Solutions, and Customer Experience.

    • 3.Strengthening cost containment measures directly related to Operations.

  • Supplementary GL issuance team, LOS monitoring
  • To ensure SLA and TAT is adhered
  • Attrition and people management
  • Reporting on Cost savings

    • 4. Case Management and complex Case reviews

  • Case Management -adhering to the PHFSA schedule& binding of R&C guides
  • Attrition and people management
  • Reporting on Cost savings
  • Audits related to Hospital bills and provider Ops issues

    • 5.Strengthening clinical and technical guidelines and assessment.

    Alignment of cashless and ‘pay and file’ & investigation claim practices across AIA and strengthening of claims decisions & clinical guidelines.

  • Building and improving guidelines that will enable better decision making and Cost savings outcomes meeting stipulated goals set for the year.

    • 6. Medical training lead

    To understand the training needs of AHS and ensure adequate training is provided to on both Cashless and reimbursement claims across Individual benefits & Employee benefits portfolios, ensure that they are competent to deliver the services in accordance with the standards set.

  • Ensuring all medical trainings are conducted with solid outcomes within and beyond AHS
  • Assisting trainers beyond AHS- customer care, contact center and CSD to strengthen their medical knowledge

    • 7. Collaborations - Within and beyond AIA

  • Ensuring Ops is abreast with latest medical advancements - Trainings and Guidelines
  • Agency level -Training & complaints Management
  • Frontliners -Branch / Contact Centre & Customer corresponding - Training on important Claims materials
  • Product and Marketing - Selection of GIO criteria / feedback on product design
  • Providers- Active discussion with doctors and hospital management in the FWA space
  • Regulator -Supporting MTA, JTC, LIAM, PIAM, Shariah Committee including presentation, meeting, and surveys.

    • 8.Investigation for Minor Claims

  • Overseeing the investigation process under minor Claims
  • Close collaboration with New Business unit- Under writing for Investigation outcome management
  • Enhancing and improving processes in place for better customer experience

    • 9. Repatriation & evacuation lead

  • Managing Advisories related to benefits and medical conditions
  • Ensuring payment process is within Stipulated SLA

    • 10. PMCM lead

  • Ensuring sustainable Utilization
  • Ensuring reporting and Queries meet the Stipulate SLA

    • 11. Others

  • Provide guidance and leadership in resolving issues and that affect the member experience.
  • Approving claims within his / her authority limit.
  • Review and approval of people movement, talent identification and development activities for the functional areas.
  • Provide guidance to direct reports in the areas of continuous improvement.
  • Work across functions with peers in other department / divisions to ensure collaboration and achievements for shared goals.
  • Interact with senior management for reporting, escalations, complaint handling, issue resolution and regulatory matters.
  • Facilitating goal-level creation for the broader function and work with managers to ensure the goals are cascaded to all team member.
  • Actively monitoring and support new product launching and provide operation support – system and resources

    • Minimum job Requirements :

  • Preferably Medical Doctor (MBBS / MD)
  • Strong business acumen with strategic thinking – ability to prognosticate factors that drive healthcare costs.
  • Good knowledge of current healthcare delivery systems and hospital billing system.
  • Good stakeholder engagement skills (Providers / internal teams)
  • Working experience in managed care organizations and insurance with familiarity with claims platforms (G400 / CRM / MCS / LA)
  • Proficiency in Insurance product knowledge and experience
  • Dynamic with enthusiasm to lead with passion to provide seamless customer experience while ensuring compliance to insurance regulations.
  • Experience in Analysis, Fraud detection is an added advantage.
    • Buat amaran kerja untuk carian ini

    Manager Audit • AIA Malaysia, Kuala Lumpur, MY