Are you passionate about making a meaningful impact in healthcare insurance space? At Great Eastern, we're redefining what it means to be a claim professional. Join a passionate team where your medical knowledge, analytical skills, and attention to detail will directly impact the lives of our customers and the future of health insurance. You'll play a vital role in ensuring our policyholders receive timely and accurate support when they need it most. You'll also be empowered to contribute to service excellence initiatives that enhance the overall claims experience. It's a career path that builds deep expertise in claims assessment and customer care.

1. Lead Complex Assessment
   Take charge of evaluating complex, high value medical claims and appeals, using your deep medical knowledge and critical thinking.  Conduct review of pending claim to ensure reserve adequacy and closure of claims in a timely manner
2. Drive Service Excellence
   Deliver accurate and timely assessment of medical claims, ensuring fair payouts in line with our service standards and adherence to policy terms.  Provide clear, empathetic communication timely to policyholders, medical professionals, and internal stakeholders, making the claims process smooth and transparent.
3. Engage with Stakeholders
   Collaborate with clinicians, hospitals, and policyholders to gather and clarify clinical information, making you a key player in the claims journey.

4. Analyze claim patterns
   Identify claim patterns and unusual or inappropriate practices and recommend improvements to strengthen claims controls and streamline claim processes.

5. Ensure Compliance
   Adhere to internal policies and external regulatory requirements to maintain integrity and trust in our claims operations.  Take accountability in considering business and regulatory compliance risks and takes appropriate steps to mitigate the risks.  Maintain awareness of industry trends on regulatory compliance, emerging threats and appropriate steps to mitigate the risks.  Highlight any potential concerns/risks and proactively shares best risk management practices.
    

• Hold a Bachelor's degree or diploma in nursing or a related healthcare discipline
• At least 8 years of experience in medical or nursing disciplines 
• Prior experience in medical claims assessment will be an added advantage
• Strong grasp of medical practices, terminology, ICD/CPT codes, and insurance policy terms
• Strong analytical skills with ability to interpret complex medical data, spot trends, and make sound decisions under pressure
• Detail-oriented with a proven track record of managing high processing volumes without compromising quality
• Are customer-focused and excellent at building relationships with stakeholders and delivering clear, empathetic communication 
• Team players: are eager to learn and grow in a fast-paced, collaborative environment that values innovation and service excellence
• Demonstrate high level of integrity, takes accountability of work and good attitude over teamwork 
• Takes initiative to improve current state of things and adaptable to embrace new changes