SPE/SME/Claim Adjudication

Key Responsibilities:

• Assess complex medical claims for APAC insurance providers similar to AXA, AIA, Alliance Care.
• Verify medical codes, diagnoses, and procedures to ensure compliance with ICD-9, ICD-10, CPT, and other industry standards.
• Review Clinical & Day Case claims and approve or reject based on SOPs.
• Analyze Hospital Inpatient & Outpatient claims, categorize benefits, and approve/reject per SOP.
• Provide guidance to junior advisors to resolve complex claims.
• Identify potential fraud, waste, and abuse (FWA); flag suspicious cases and collaborate with compliance teams for early detection and escalation.