Role Summary
This specialist role focuses on risk management and cost containment by identifying fraud, waste, and abuse in medical claims. It requires expertise in medical advisory to handle disputed charges and audits within the insurance framework.
Job Description
As a Medical Advisory, Case & Fraud Management Specialist, you will identify patterns of fraud, waste, and abuse in medical claims. Key tasks include conducting surgical history checks, implementing risk management measures, and performing reviews of hospitalizations to ensure cost containment without compromising care quality. You will also provide medical advisory on disputed charges and appeals, maintain fraud analysis tools, and conduct robust training for staff and healthcare providers. The role involves mentoring team members and collaborating on system improvements.
Job Requirements
Minimum Bachelor's Degree or Diploma in a relevant field.
At least 5 years of experience in medical claims processing.
Proficient in medical coding, MOH letters, and reasonable charges.
Strong knowledge of health insurance policies and medical reports.
Ability to identify breach of duty and non-disclosure in claims.
Experience in conducting audits and case management for fraud detection.
Quick Info
Company
—
Location
Kuala Lumpur
Salary
Undisclosed
Skills Required
9 skills
Click to submit your application
Required Skills
Medical Advisory
Case Management
Fraud Management
Claims Assessment
Medical Coding
Risk Management
Health Insurance Policy
Auditing
Cost Containment
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