The position entails a qualified and experienced medical profession to support our claims teams in various lines of business, namely individual life, health and group employee benefits, concerning but not limited to claims assessment, adjudication and cost containment. The ideal candidate is pivotal in ensuring the integrity, fairness and accuracy of medical claims decisions. The individual is also involved in representing the claims team in case of adjudication disputes, e.g. FIDReC wherever medical expertise is required; and will represent PACS in industry-wide medical discussions, e.g. Integrated shield (PRUShield) to support our commitment in delivering trusted protection and valued service to our customers.
Roles and Responsibilities:
Medical Evaluation & Claims Assessment:
- Review and interpret complex medical reports, diagnostic test results, and treatment plans to assess validity of claims, ensuing medical necessities and appropriate treatment regime vis--vis severity.
- Provide expert medical opinions on complex or high-value claims across various products and business lines.
- Ensure alignment with policy definitions, exclusions and industry best practices, supported with objective evidence
Documentation Review and Compliance:
- Analyse submitted documentations corroborated with policy definitions, exclusions clauses and regulatory / industry standards
- Ensure compliance with industry best practices and provide recommendations based on medical knowledge and available evidence
Stakeholder Collaboration:
- Work closely with claims assessors, underwriters, legal, product team and external medical providers to support decision-making processes.
- Engage with the distributors and customers independently whenever complex medical advice is required to justify claims decisions.
- Participate in underwriting and claims committees to align medical assessment in accordance with claims guidelines and business objectives
- Discuss with reinsurers, where necessary, providing expert medical insights, supporting reviews and resolution of complex cases.
Reporting & Recommendations:
- Prepare detailed, clear and concise case summary with substantiated recommendations relating to the claim outcomes.
- Provide actionable insights to improve decision-making process and claims evaluation efficiency.
Policy Guidance & Advisory:
- Advise on medical aspects of policy wordings, including exclusions, terms and regulatory directives.
- Contribute to the development and enhancement of policy wording based on medical best practices.
- Involved in the review and alignment of Life Insurance Association (LIA) Critical Illness definitions, ensuring common definitions are updated and consistent with medical advancements and product intent.
Training & Development:
- Conduct internal training sessions to enhance medical literacy and claims evaluation skills within the claims team.
- Ensure claims team is abreast with medical advancement, treatment protocols, clinical guidelines and regulatory changes/requirements.
Continuous Improvement:
- Contribute to process enhancements and best practices in medical claims evaluation especially in cost containment, fraud prevention, avoidance and abuse
- Identify opportunities or areas of improvements in operational efficiency and quality of medical claims management
Qualifications(minimum education level or / and professional qualification):
- At least a basic medical degree (MBBS or equivalent) from a recognized institution
- Holds a valid medical license/registration in Singapore
Work Experiences:
- Minimum 5 years of clinical experience
- Prior experience in insurance, claims assessment, or occupational health is highly desirable.
- Familiarity with ICD coding, medical terminology, interpretation of ECG & laboratory readings, pathology/radiology/scans etc reports and insurance policy structures.
Personality Traits:
- Strong communicator with positive influence
- Excellent written and verbal communication skills in English.
- Analytical mindset with keen attention to detail and sound ethical judgment.
- High level of professionalism and discretion
- Capable of working independently and self-driven
- Adaptable & thrive in dynamic work environment
- Design focused, resourceful, and results-driven withhands-on approach .
Competencies / Knowledge:
- Good understanding of the financial industry, and familiarity with insurance operations
- Knowledge of MOH and MAS regulations, along with industry guidelines relevant to life & health insurance industry
