Medical Adjudication Specialist

1 week ago

Singapore AIA SINGAPORE PRIVATE LIMITED Full time
Roles & Responsibilities

Responsibilities:

  • Review and adjudicate complex medical claims, especially outliers, to identify potential fraud, waste, or abuse (FWA).
  • Collaborate with medical providers, third party administrators, and internal stakeholders to investigate questionable claims and perform fact-finding when discrepancies arise.
  • Negotiate with service providers on unreasonable charges and challenge inflated or non-medically necessary items.
  • Apply evidence-based clinical knowledge to support fair, consistent decisions, ensuring adherence to company policy and regulatory frameworks.
  • Lead discussion with agents, administration teams, and policyholders to explain adjudication outcome, ensuring clarity.
  • Contribute insights to the development of automated adjudication tools, AI driven fraud detection, and continuous process improvements.
  • Meet SLA timelines for claims adjudication, reporting, and closure.
  • Provide expert recommendations on emerging FWA trends and recommend preventive strategies.

Requirements:

  • 3-5 years Clinical or operation theatre experience in Singapore
  • Strong understanding of surgical codes
  • Strong clinical reasoning and analytical thinking.
  • Communication and negotiation skills (dealing with policyholder, agents and healthcare providers).
  • Computer literacy – Microsoft Word and Excel
  • Insurance-related and health insurance adjudication experience a plus
  • Suitable for nurses who are looking for a career change
Tell employers what skills you have
Manage stakeholders
Microsoft
Fraud Investigations
Claims Management
Microsoft Excel
Engaging with stakeholders
Fraud Detection
Claims
Claim Investigation
Surgical Nursing
Fraud
Medical/Surgical
Computer Literate
Surgical
Communications
Microsoft Word

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