Role Overview:

As a Claims Assessor, you will be responsible for evaluating medical claims, particularly hospitalization and clinical claims, for group insurance policies. This role ensures claims are processed efficiently, accurately, and in a timely manner, while maintaining excellent service levels and confidentiality.

Key Responsibilities:

· Review and assess inpatient (IP) and outpatient (OP) claims—including medical, surgical, and hospital cases—for accuracy, completeness, and compliance with policy requirements.

· Ensure claims are processed in accordance with policy coverage, terms and conditions, regulatory standards, and internal guidelines.

· Carry out daily claims processing and checks, ensuring timely settlement within agreed turnaround times (TAT).

· Analyse CPF rejections by identifying root causes, resolving discrepancies, and implementing corrective actions to minimise recurrence.

· Perform daily second-level checks to maintain quality, consistency, and compliance in claims handling.

· Conduct weekly appeal audits to validate decisions, ensure proper case handling, and support continuous improvement.

· Investigate complex cases and client complaints, providing effective and timely resolutions while maintaining service quality.

· Liaise with healthcare providers, policyholders, and internal stakeholders to obtain required information for accurate claims evaluation.

· Identify and flag potentially fraudulent claims or irregular patterns, escalating cases according to established protocols.

· Collaborate with team members and supervisors to improve processes, enhance efficiency, and support quality initiatives.

· Maintain accurate and complete documentation of claims assessments, decisions, audits, and reviews for reporting and audit readiness.

Key Requirements:

Diploma or higher educational qualification.

Strong knowledge of health insurance policies and claims processes.

At least 1 year of experience in claims assessment, preferably in health or insurance setting.

Ability to interpret medical reports and understand medical terminology.

Excellent analytical and decision-making skills.

Meticulous and high accuracy in claims processing.

Good communication skills, both written and verbal.

By submitting your application, you grant consent to Fullerton Health and affiliates to utilize your information to assess job suitability and be considered for other suitable positions.