Sr. Claim Quality Audit

5 days ago

Pathum Wan, Bangkok, Thailand Allianz Ayudhya Assurance Public Company Limited Full time

Nice to know

Being responsible for claim quality audit and report preparation in timeline. Also, claim analysis project and the activities related to its results.

Your Day at Allianz Ayudhya

  1. Claim Quality Audit

· Regular claim quality review and feedback result to team.

· Random checking Reimbursement claims both individual and group (E-claim submission, Auto-Paid).

· Random checking Hospital Assessment claims both individual and group.

· Random checking Fax Claim cases.

· Best Practice Sharing case study in monthly meeting to team.

· QA Monthly report and KRI report preparation

  1. Claim Monthly Report

· Regular review and analyze claims data from IT.

· Prepare the claim monthly report to team.

· Find out the abnormal claim pattern in various dimensions e.g. number of claim transactions, number of claimants, distribution channels and hospitals etc.

· Cooperation with team and take actions in claims part such as high claim cases by doing not renew process, issue agent warning letter, closely claim monitoring and add their name list in UC file

  1. Claims Analysis

· Analyze big claim data to find out the abnormal claims pattern.

· After getting the analytic report, support by

  • Reviewing claim data as the criteria setting e.g. claim visiting count, early claim count, last claim visiting duration etc.
  • 1st step of visual inspection to screen and select the suspicious cases.
  • 2nd step of details investigation by reviewing all documents (application, all coverage, claim history, claim documents, agent details, claims payment amount.
  • Summary total suspicious cases and all actions.
  • Take actions as team decision such as not renew process, issue agent warning letter, closely claim monitoring and add their name list in UC file.
  • Regularly practice for this function as above procedure.

Must Have

  • Degree in Business Administration, Nursing, Business of Sciences (Medical Technology), orany related field
  • At least 5 years' experience in Nursing practice,Claims Management, Claim Audit or other related fields in insurance industry
  • Knowledge of claims management policies and processes and insurance industry and product
  • Knowledge of insurance contract law, industry standards, the legal and regulatory framework
  • Experience working with probability and statistics to develop forecasts and projections

Nice to Have

  • Accuracy concern & detail orientation
  • Recognition of trends, benefits, and implementation of business opportunities, process optimization
  • Experience in using claims/CRM systems
  • Knowledge of Claims Auditing Software (e.g. Oracle Insurance Claims, Xactimate, Claim Center etc.
  • Knowledge of collaborative project management tools (e.g. Trello, JIRA, Asana etc.)
  • Experience in data collection, evaluation, and interpretation, familiar with data software such as Excel Advance, PowerBI
  • Any AI-future skills e.g., ChatGPT, or CoPilot365, will be advantage.

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