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Claims & Operations Analyst

Insurance • Causeway Bay, Hong Kong, HK • 1d ago

Key Responsibilities:

Claims Investigation & Fact-Finding
- Conduct detailed claim investigations upon client requests (e.g. disputes, potential frauds etc).
- Organise policy terms, provider contracts, and billing data to validate claims accuracy.
- Document findings and support Medical Director in resolutions for complex cases.
Data Analytics & Operational Efficiency
- Extract and analyze claims data to support Medical Director’s identification of trends (e.g. delays, provider billing patterns).
- Develop SLA dashboards (e.g. turnaround time, backlog) and key metrics reports for clients.
- Support transactional accounting (AR/AP) by reconciling claims payments vs. provider invoices.
Policy & Financial Administration
- Ensure claims align with policy terms, and agreed fee schedules, and corporate guidelines.
- Verify samples of financial accuracy in accounts receivable (provider payments) and accounts payable (client reimbursements).
- Collaborate with Finance to resolve discrepancies in claim settlements.
Client & Provider Collaboration
- Address client ad-hoc requests for claims analytics (e.g., cost drivers, utilization trends).
- Clean instructions and requirements for provider teams to resolve billing disputes and clarify payment issues.
Documentation & Reporting
- Maintain accurate and up-to-date records of all claims and related correspondence.
- Prepare regular reports and summaries for the Medical Director, highlighting trends, discrepancies, and areas for improvement.
- Support audit and compliance checks by organizing and providing necessary documentation.
Cross-Unit Support
- Coordinate with the operations teams, Drugs Trading, Doc Net TPA, and Heals Clinic Teleconsultation to streamline claims workflows, etc.
- Ensure consistency in claims handling procedures across all business units.
Administrative Support
- Schedule and coordinate meetings related to claims management.
- Draft internal communications and assist in the development of claims-related SOPs and training materials.

Qualifications:

Diploma or Bachelor's degree in healthcare admin, Business, or a related field.
Minimum 1–2 years of experience in claims processing, healthcare administration, or insurance.
Familiarity with medical terminology and healthcare systems is an advantage.
Proficient in Microsoft Office Suite (Excel, Word, PowerPoint).
Strong organizational skills and attention to detail.
Excellent communication and interpersonal skills.

Work Environment:

Onsite office with occasional travel to clinics or partner offices as needed.
Collaborative and fast-paced environment with opportunities for cross-functional learning.

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