SPE / Claim Adjudication – Health Insurance (Hong Kong Shift)

• Assess complex health insurance claims and ensure compliance with industry standards (ICD 9, ICD 10, CPT)

• Review clinical, day case, inpatient, and outpatient claims to approve or reject as per SOP

• Identify potential fraud, waste, and abuse (FWA) and escalate suspicious cases

• Document all claim-related activities in the claims management system

• Respond to policyholder inquiries regarding claim status and documentation

• Support junior advisors in resolving complex claims and mentor them on best practices

• Conduct quality audits of processed claims to ensure accuracy and regulatory compliance

• Assist in continuous improvement initiatives to enhance claims processing efficiency

• Collaborate with internal departments to gather missing documentation or information

• Maintain confidentiality and adhere to data protection standards

• Support training sessions on claims systems and regulatory updates