SPECIALIST, MEDICAL INSURANCE

Job Purpose

Performing medical insurance activities efficiently, in timely manner and quality standards as per the defined policies and procedures to achieve departmental operational plans and developments.

Key Accountability Areas

Medical Insurance Operations:

• Perform medical insurance policy renewals and support the submission process with brokers and insurance providers.
• Review and process employee enrollment, additions, deletions, and policy amendments.
• Receive and review statements of account and forward them to the Accounting Department for further processing.
• Process medical insurance claims, reimbursement requests, and pre-authorizations in accordance with policy provisions.
• Follow up on claims settlement status, outstanding cases, and related invoices with insurers and third-party administrators (TPAs).
• Review claims utilization reports and identify discrepancies for further investigation.

Policies and Procedures:

• Review medical insurance policy terms, conditions, benefits, and exclusions and highlight issues or concerns for consideration during policy renewal.
• Provide information and guidance to employees regarding medical insurance coverage, benefits, network providers, and claims procedures.
• Liaise with insurance brokers, insurers, and TPAs regarding policy interpretation and coverage-related inquiries.
• Maintain awareness of changes in medical insurance regulations, products, and market practices.
• Verify compliance of medical insurance documentation with company policies and insurance requirements.

Employee and Service Support:

• Participate in meetings with brokers, insurers, and internal stakeholders regarding medical insurance matters.
• Monitor service delivery by brokers, insurers, and TPAs and report service-related issues when identified.
• Support the implementation and analysis of employee satisfaction surveys related to medical insurance services.
• Respond to employee inquiries and assist in resolving medical insurance-related issues.
• Follow up with insurers and healthcare providers regarding claim processing and coverage matters.

Analysis and Coordination:

• Assist in reviewing medical claims experience, utilization trends, and insurance reports.
• Coordinate with brokers and insurers in gathering information related to medical insurance coverage and benefits.
• Review employee medical insurance requirements and provide supporting information for coverage recommendations.
• Assist in collecting and compiling data related to healthcare utilization and insurance performance.

Filing and Documentation:

• Maintain and archive medical insurance policies, endorsements, claims records, correspondence, and supporting documents.
• Ensure medical insurance records and employee insurance data are complete, accurate, and up to date.
• Maintain organized filing systems for insurance documentation and records.

Reports:

• Prepare and coordinate periodic reports related to medical insurance operations, claims activity, utilization, and service performance.
• Compile and verify insurance-related data for management reporting purposes.
• Support the preparation of renewal and insurance performance reports.

Role Accountability

HR Proficiency:

• Ability to obtain updated soft and technical skills related to the job.

Delivery:

• Perform the planned activities to meet the operational and development targets as per delivery schedules.
• Utilize resources effectively to achieve objectives within efficient cost and time.
• Provide a periodic report formatted by detailing the deviation and execution of planned tasks.

Problem-Solving:

• Solve any related problems arise and escalate any complex operational issues.

Quality:

• Ensure quality requirements to develop effective quality control and processes including specifications for products or processes or related activities.

Business Process Improvements:

• Coordinate well-defined written systems, policies, procedures, and seek automations opportunities as much as possible.

Compliance:

• Comply to related policy and procedures and work instructions.

Health, Safety, and Environment:

• Ensure compliance of relevant safety, quality, and environmental management procedures and controls within defined area of work activity to guarantee safety, legislative compliance, and delivery of high-quality products/services.

Academic Qualification

Work Experience

Technical / Functional Competencies