Claim Assessment Senior Specialist (Chuyên viên Cấp cao Dịch vụ Thẩm định Bồi thường)
Core
Senior specialist adjudicating healthcare claims (reimbursement and direct billing), assessing medical necessity, and ensuring risk control within quality assurance frameworks.
Role type
Senior IC claims adjudicator (healthcare)
Builds
Accurate claims decisions and payment calculations for healthcare providers and customers
Domain
Insurance / Healthcare
Required skills
Healthcare claims adjudication, Medical necessity assessment, Risk control, Audit of insurance/hospital claims, Policy interpretation, Data analysis (MS Excel)
Preferred skills
Customer service in healthcare, Life insurance claims processing, System automation support, Project management
Technologies
RCS, TPA portal, MS Excel, MS Word, MS PowerPoint
Responsibilities
Process daily claims volume within SLA and quality standards, Review complex or referred cases for adjudication, Audit monthly claims cases for quality assurance, Communicate with customers/hospitals for case clarification, Prepare case studies for policy coverage or exceptional handling, Support automation manager to rectify productivity issues
Seniority
Senior, hands-on IC