Medical Claims Consultant

Prudential’s purpose is to be partners for every life and protectors for every future. Our purpose encourages everything we do by creating a culture in which diversity is celebrated and inclusion assured, for our people, customers, and partners. We provide a platform for our people to do their best work and make an impact to the business, and we support our people’s career ambitions. We pledge to make Prudential a place where you can Connect, Grow, and Succeed.

Job Summary

Roles and Responsibilities:
Medical Evaluation & Claims Assessment:

- Review and interpret complex medical reports, diagnostic test results, and treatment plans to assess validity of claims, ensuing medical necessities and appropriate treatment regime vis-à-vis severity.
- Provide expert medical opinions on complex or high-value claims across various products and business lines.
- Ensure alignment with policy definitions, exclusions and industry best practices, supported with objective evidence

Documentation Review and Compliance:

- Analyse submitted documentations corroborated with policy definitions, exclusions clauses and regulatory / industry standards
- Ensure compliance with industry best practices and provide recommendations based on medical knowledge and available evidence

Stakeholder Collaboration:

- Work closely with claims assessors, underwriters, legal, product team and external medical providers to support decision-making processes.
- Engage with the distributors and customers independently whenever complex medical advice is required to justify claims decisions.
- Participate in underwriting and claims committees to align medical assessment in accordance with claims guidelines and business objectives
- Discuss with reinsurers, where necessary, providing expert medical insights, supporting reviews and resolution of complex cases.

Reporting & Recommendations:

- Prepare detailed, clear and concise case summary with substantiated recommendations relating to the claim outcomes.
- Provide actionable insights to improve decision-making process and claims evaluation efficiency.

Policy Guidance & Advisory:

- Advise on medical aspects of policy wordings, including exclusions, terms and regulatory directives.
- Contribute to the development and enhancement of policy wording based on medical best practices.
- Involved in the review and alignment of Life Insurance Association (LIA) Critical Illness definitions, ensuring common definitions are updated and consistent with medical advancements and product intent.

Training & Development:

- Conduct internal training sessions to enhance medical literacy and claims evaluation skills within the claims team.
- Ensure claims team is abreast with medical advancement, treatment protocols, clinical guidelines and regulatory changes/requirements.

Continuous Improvement:

- Contribute to process enhancements and best practices in medical claims evaluation especially in cost containment, fraud prevention, avoidance and abuse
- Identify opportunities or areas of improvements in operational efficiency and quality of medical claims management

Qualifications (minimum education level or / and professional qualification):

- At least a basic medical degree (MBBS or equivalent) from a recognized institution
- Holds a valid medical license/registration in Singapore

Work Experiences:

- Minimum 5 years of clinical experience
- Prior experience in insurance, claims assessment, or occupational health is highly desirable.
- Familiarity with ICD coding, medical terminology, interpretation of ECG & laboratory readings, pathology/radiology/scans etc reports and insurance policy structures.

Personality Traits:

- Strong communicator with positive influence
- Excellent written and verbal communication skills in English.
- Analytical mindset with keen attention to detail and sound ethical judgment.
- High level of professionalism and discretion
- Capable of working independently and self-driven
- Adaptable & thrive in dynamic work environment
- Design focused, resourceful, and results-driven with hands-on approach.

Competencies / Knowledge:

- Good understanding of the financial industry, and familiarity with insurance operations
- Knowledge of MOH and MAS regulations, along with industry guidelines relevant to life & health insurance industry