Nurse Claim Assessor

1. Review and evaluate matters relating to the payment of individual insurance claims for critical illness and inpatient (IPD) cases, consisting of

• receiving and sorting claim documents sent from various units such as administration, customers, and agents, and recording them in the document registry
• checking the benefits from the coverage purchased by the customer and verifying the accuracy and completeness of claim documents
• reviewing pre-existing conditions and submitting medical investigation/requesting medical history
• approving claim payments
• coordinating with agents/customers to provide information on claims and claim assessment.

2. Provide information and guidance to staff in the Hat Yai, Chiang Mai, and Khon Kaen regional offices in cases where staff have problems or questions, including reviewing payments and health claim assessments (audit).

3. Act as third-party administrator for other companies contracting MTL, by reviewing, evaluating, and approving direct health claim payments, as well as providing consultation, advice, and decisions in claim cases where staff have problems, questions, or are unable to make an assessment.

4. Coordinate with field data teams to obtain additional information on the insured for claim assessment, follow up with field data teams and hospitals to obtain information within the required timeframe, and prepare monthly summaries of the number of medical investigations and their results for submission to supervisors.

5. Answer various questions from the insured or agents.

6. Read and analyze the medical history of the insured and prepare analytical summaries for consideration of approval or rejection of claims as requested.

7. Prepare documents and coordinate with the reinsurance team to seek approval from reinsurers.

Qualifications:

Education

Bachelor’s degree in Nursing or Medical Technology or higher

Work Experience

At least 2 years of professional nursing experience. Experience in life insurance would be an advantage.

Skills

• Analytical thinking, communication, and coordination skills. Service-minded, with good interpersonal skills, diligence, and perseverance.
• Ability to analyze diseases and read medical documents.
• Ability to use English, computers, and basic software applications.
• Knowledge of claims and insurance systems.
• Ability to analyze health information, medical records, and hospital records, such as laboratory test results, types of medication used, and treatment methods related to various diseases.