เจ้าหน้าที่พิจารณาสินไหม - บริษัท อลิอันซ์ อยุธยา ประกันภัย จำกัด (มหาชน)

Role Overview

Specialist – Claim Reimbursement is responsible for supporting end‑to‑end claims assessment for reimbursement and OPD cashless claims. This role ensures timely, accurate, and compliant claim decisions, manages complex cases, monitors pending workloads, and collaborates with internal stakeholders to uphold operational standards and service excellence.

Key Responsibilities

1) Claims Reimbursement

• Support the team in investigating and making claim assessment decisions.
• Approve claim payments in accordance with authorization limits.
• Perform claim rejection when criteria are not met.
• Request additional information or documentation when required.
• Issue memos in the system to support administrative processing.
• Submit cases for further investigation when necessary.
• Request hospital medical records to support claim review.
• Continuously monitor, review, and make decisions on pending or backlogged reimbursement cases.
• Consolidate complex cases and prepare documentation for Claim Committee and COO/CEO for decision‑making based on authorization guidelines.

2) Hospital Assessment – OPD Cashless

• Handle OPD cashless claims submitted by hospitals.
• Perform investigation and make claim decisions for OPD cashless cases in the system.
• Approve claim payments according to authorization levels.
• Perform rejection for fax‑submitted claims when applicable.
• Request additional information as needed to complete assessment.
• Issue memos in the system for administrative follow‑up.
• Submit cases for further investigation when necessary.
• Request hospital records and supporting documents.
• Monitor and decide on pending OPD cashless cases and backlog items.
• Manage and present complex OPD cashless cases requiring Claim Committee decisions.
• Ensure claim approvals are accurate, timely, and aligned with service-level agreements (SLAs).

Must Have Qualifications

• Bachelor’s degree in Nursing Science, Medical Technology, or related field.
• Minimum 3 years of experience as a Claims Assessor or in relevant functions within the insurance industry.
• Strong knowledge and understanding of nursing/medical concepts, insurance claim regulations, policies, and guidelines.

Nice to Have

• Strong attention to accuracy and detail.
• Experience in claims or CRM systems.
• Ability to prioritize claim‑related tasks efficiently.
• Proficiency in MS Office, especially Advanced Excel, PowerPoint, Power BI, and other data software tools.
• Familiarity with AI‑related tools (e.g., ChatGPT, Microsoft Copilot 365) is an advantage.