Effective communication skills, including the ability to explain claim decisions, document findings, and collaborate with internal and external stakeholders.
High attention to detail and accuracy in data entry and documentation.
Ability to work in a fast-paced environment, manage multiple cases, and meet processing timelines.
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Ensure claims are processed within defined turnaround time (TAT), productivity, and quality benchmarks, balancing speed with accuracy and service excellence.
Identify, investigate, and escalate potential fraud, abuse, or leakage risks, working closely with the Fraud Investigation Unit and relevant stakeholders to support effective risk mitigation.
Manage claims requiring additional information by preparing clear, professional, and compliant correspondence to claimants, healthcare providers, and third parties, ensuring timely follow‑ups and resolution.
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Conduct claimant, provider or third‑party interviews where required, ensuring adherence to investigation protocols, professionalism and non‑tipping‑off principles
Verify claim documentation and supporting records, identifying indicators of forged, altered or inconsistent information using structured review methods and available digital validation tools
Prepare clear, accurate and well‑documented investigation findings, case notes and reports for review, escalation or submission to the SG Fraud team
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Leverage available automation and AI-enabled tools to enhance assessment efficiency, consistency, and accuracy
Liaise with Medical Advisors to obtain clinical guidance and clarification where required, ensuring informed and well supported claim decisions.
Perform effective suspense management, follow up on outstanding requirements, and liaise with Finance and relevant stakeholders to ensure timely and accurate claim payments.
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Performs other responsibilities and duties periodically assigned by immediate manager in order to meet business requirements.
Prepares regular reporting to management on metrics relating to business, operations, risk, compliance, workforce, etc. or statutory authorities on regulatory metrics.
Develop procedures for reporting, extract, collate and populate data to reporting template.
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