APAC Region candidates only target organization AXA, AIA, QBE, Alliance Care,etc.

Claims Excellence - Health Insurance (Hong Kong)

Processor Role

Job Responsibilities and Expectations

Mandatory Pointer

- SPE and SME -25 open numbers (Exp.2-6years) Location-Coimbatore.
- Apac Region Experience candidates only .
- Target companies like - NLGIC, Star Health, Galaxy, AIA, Alliance, AXA etc.
- Manual Claims Adjudication experience

- Assess complex medical claims similar to AXA, AIA, Alliance Care
- Verify medical codes, diagnosis and procedure to ensure compliance with industry standards (e.g. ICD 9, ICD 10, CPT)
- Review Clinical & Day Case claims and approve/reject basis the SOP
- Review Hospital Inpatient & Outpatient Claims, analyze the vouchers/medical documents, categorize the benefits as per the SOP and approve/reject basis the SOP
- Provide guidance and support to facilitate junior advisors resolve complex claims
- Identify potential fraud, waste, and abuse (FWA) Flag suspicious cases, highlight patterns, and work with compliance teams to ensure early detection and escalation.

Questionnaire Q1. What is Insurance Claim ?

Q2. What are the Steps of Claim used in Apac Region ?

Q3. What is your understanding about the Manual Claims adjudication ?

Q4. What is ICD9 and ICD10 give detailed answer on the same with examples of the work done by them, the basic codes used universally needs to be mentioned correctly?

Q5. Give an example of correct Diagnosis Interpretation?

Experience

- 2-5 Years of Experience in the above listed work type/life science background/CPC certified
- - 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 effective 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 [email protected] www.orcapodservices.com

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📌 SPE/Claim Adjudication/APAC/Hongkong shift (Coimbatore)
🏢 Orcapod Consulting Services
📍 Coimbatore