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