Claim excellence
- Cognizant
- 4 - 8 years
- Coimbatore
- 3 months ago
- Email to a friend
- Report this job
Job Description
Claims Excellence - Health Insurance (Hong Kong)
Processor Role
Job Responsibilities and Expectations
- - Assist in validating and processing health insurance claims in accordance with Hong Kong Insurance Authority (IA) guidelines.
- - Ensure accurate data entry and documentation of claim details in the claims management system.
- - Support the review of claims for completeness and compliance with policy terms and conditions.
- - Coordinate with internal departments to gather missing documentation or information.
- - Flag potential discrepancies or anomalies for further review.
- - Maintain confidentiality and data protection standards in handling sensitive health information.
- - Respond to basic inquiries from policyholders regarding claim status and documentation requirements.
- - Ensure timely processing of claims to meet service level agreements (SLAs).
- - Assist in generating reports for internal tracking and audit purposes.
- - Stay updated on changes in claims procedures and regulatory requirements in Hong Kong.
- - Support continuous improvement initiatives in claims processing workflows.
- - Participate in training sessions related to claims systems and regulatory updates.
- Service and resolve inquiries from customers, members, beneficiaries, and others regarding Health Care products and benefits across multiple product lines
- Ability to communicate effectively across multiple channels, including phone, e-mail, chat, and text
- Ability to succinctly collect information from a customer to set up a new claim
- Ability to gather information from multiple source systems to understand and articulate the status of a claim and what information may be needed, next steps in processing, etc.
Academic and Additional Qualifications Needed
- - Bachelors degree in Insurance, Business Administration, Healthcare Management, or related field.
- - Basic understanding of health insurance products and claims lifecycle.
- - Proficiency in Microsoft Office and claims management software.
- - Strong attention to detail and organizational skills.
Quality Review Role
Job Responsibilities and Expectations
- - Conduct quality audits of processed claims to ensure accuracy and compliance with IA regulations.
- - Identify patterns of errors and recommend corrective actions to improve claims processing quality.
- - Collaborate with processors to provide feedback and training on claim adjudication standards.
- - Ensure claims are processed in alignment with policy terms and regulatory guidelines.
- - Prepare quality review reports and present findings to management.
- - Monitor adherence to SLAs and escalate issues impacting service delivery.
- - Support implementation of quality assurance frameworks and continuous improvement initiatives.
- - Review documentation and system entries for completeness and accuracy.
- - Assist in regulatory audits and internal compliance checks.
- - Stay informed about updates in claims regulations and industry best practices.
- - Participate in cross-functional meetings to align quality standards across departments.
- - Mentor junior staff on quality expectations and documentation standards.
Academic and Additional Qualifications Needed
- - Bachelors degree in Insurance, Business Administration, Healthcare Management, or related field.
- - 35 years of experience in health insurance claims processing or quality assurance.
- - Strong analytical and documentation review skills.
- - Knowledge of Hong Kong IA claims regulations and compliance standards.
Supervisor Role
Job Responsibilities and Expectations
- - Oversee daily operations of the claims excellence team ensuring adherence to IA regulations.
- - Manage workload distribution and monitor team performance against SLAs.
- - Provide guidance and support to processors and quality reviewers on complex claims.
- - Resolve escalated issues and ensure timely communication with policyholders and providers.
- - Implement process improvements to enhance claims accuracy and turnaround time.
- - Conduct regular team meetings and training sessions on regulatory updates and system enhancements.
- - Review and approve high-value or complex claims in accordance with policy terms.
- - Coordinate with compliance and legal teams on disputed claims and regulatory matters.
- - Monitor KPIs and prepare performance reports for senior management.
- - Ensure proper documentation and audit readiness across all claims activities.
- - Support recruitment and onboarding of new team members.
- - Foster a culture of excellence, accountability, and continuous learning.
Academic and Additional Qualifications Needed
- - Bachelors degree in Insurance, Business Administration, Healthcare Management, or related field.
- - 58 years of experience in health insurance claims operations with supervisory responsibilities.
- - Strong leadership and team management skills.
- - In-depth knowledge of Hong Kong health insurance regulations and claims adjudication practices.
Manager Role
Job Responsibilities and Expectations
- - Lead the strategic direction of the claims excellence function in alignment with organizational goals.
- - Ensure full compliance with Hong Kong IA regulations and internal governance standards.
- - Develop and implement policies and procedures for efficient claims management.
- - Drive initiatives to improve claims accuracy, fraud detection, and customer satisfaction.
- - Represent the claims department in regulatory audits and industry forums.
- - Collaborate with IT, legal, and compliance teams to enhance claims systems and workflows.
- - Monitor industry trends and regulatory changes to proactively adapt claims strategies.
- - Manage departmental budgets and resource allocation.
- - Establish performance benchmarks and oversee achievement of operational targets.
- - Mentor and develop leadership capabilities within the claims team.
- - Handle escalations involving complex or high-profile claims.
- - Promote a culture of compliance, innovation, and service excellence.
Academic and Additional Qualifications Needed
- - Bachelors or Masters degree in Insurance, Business Administration, Healthcare Management, or related field.
- - 10+ years of experience in health insurance claims operations with managerial responsibilities.
- - Proven track record in regulatory compliance and operational leadership.
- - Expert knowledge of Hong Kong health insurance regulations and claims governance.
Valid PAN Number - _____________________(Why PAN Required > Mandatory to Process Candidature & Find Duplicity in Internal PAN Validation Process and also to initiate a screening call.
Please reach out in case of any queries.
Sonali Chattopadhyay I Associate People Success
Orcapod Consulting Services Pvt Ltd.
Email I so*****************y@or****d.work
www.orcapodservices.com
9548431***
Job Classification
Industry: BPM / BPOFunctional Area / Department: Healthcare & Life SciencesRole Category: Healthcare & Life Sciences - OtherRole: Healthcare & Life Sciences - OtherEmployement Type: Full timeContact Details:
Company: CognizantLocation(s): Coimbatore+ View Contact
Keyskills: Health Insurance Claims Claim excellence Documentation US Healthcare processing of claims Data Entry
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