Job Location : Malaysia
Summary :
The Medical Claim Advisor handles appeal and more complex claims, provide guidance to junior advisors and new joiners to ensure high standards of accuracy and efficiency in claim processing. This role requires advanced knowledge of medical claims procedures and the ability to resolve escalated issues while maintaining compliance with regulations.
Roles & Responsibilities:
1. Review outpatient, day-care, and inpatient medical claims in accordance with policy terms, conditions, and Standard Operating Procedures (SOPs).
2. Analyze medical reports, discharge summaries, treatment records, invoices, and supporting documentation to determine claim eligibility.
3. Verify medical diagnoses, procedures, and treatment details using industry-recognized coding standards such as ICD-9, ICD-10, and CPT.
4. Categorize medical expenses under the appropriate benefit heads and accurately adjudicate claims based on policy coverage and available products.
5. Approve, reject, or adjust claims in line with policy exclusions, limits, and benefit entitlements.
6. Ensure completeness and accuracy of claim documentation and system updates.
7. Maintain productivity, quality, and turnaround time targets.
8. Support Advisors in resolving complex claim scenarios and policy interpretation queries.
9. Provide coaching, training, and knowledge-sharing sessions to improve team capability.
10. Identify unusual claim patterns, discrepancies, or potential Fraud, Waste, and Abuse (FWA) indicators and escalate appropriately.
11. Collaborate with HK Claims Team to conduct assessment and investigation if needed.
Experience:
1. With 1 - 5 years of experience in medical claims handling
2. With healthcare background is preferred
3. With in-depth knowledge of medical terminology, billing codes (ICD 9, ICD 10, CPT) and medical insurance polices is preferred
4. Strong team player, willing to learn, able to work independently and effectively under pressure
5. Proficiency in claims management system
Language : Must be Proficient in Cantonese (Written & Verbal)
About Cognizant:
Cognizant (Nasdaq: CTSH) engineers modern businesses. We help our clients modernize technology, reimagine processes and transform experiences so they can stay ahead in our fast-changing world. Together, we're improving everyday life. See how at www.cognizant.com or @cognizant.
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About Cognizant:
Cognizant (Nasdaq: CTSH) is an AI Builder and technology services provider, bridging the gap between AI investment and enterprise value by building full-stack AI solutions for our clients. Our deep industry, process and engineering expertise enables us to build an organization’s unique context into technology systems that amplify human potential, drive tangible outcomes and keep global enterprises ahead in a fast-changing world. See how at cognizant.ai or @cognizant.
Additional employment information
Compensation information is accurate as of the date of this posting. Cognizant reserves the right to modify this information at any time, subject to applicable law.
Applicants may be required to attend interviews in person or by video conference. In addition, candidates may be required to present their current state or government issued ID during each interview.
Cognizant is an equal opportunity employer. Your application and candidacy will not be considered based on race, color, sex, religion, creed, sexual orientation, gender identity, national origin, disability, genetic information, pregnancy, veteran status or any other characteristic protected by federal, state or local laws.
