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Lead medical advisory & fraud detection initiatives as Manager at Prudential in Kuala Lumpur.
Drive policy development, audits, and AI-based fraud tools to protect health claim integrity.
Introduction
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.
The manager provides leadership and guidance to the team in the key responsibilities below:
1. Provide medical advisory, conduct audits, improve loss ratio, reduce and prevent claim leakages
2. Policy Development and Oversight
- Develop and update policies related to FWA management.
- Ensure compliance with FWA policies.
- Regularly review and update policies.
3. Fraud Waste Abuse Detection and Prevention
- Implement and manage AI and machine learning algorithms for detecting fraudulent claims.
- Oversee the development and deployment of tools and systems to identify patterns and anomalies indicative of FWA.
- Detect and reduce the number of fraudulent claims.
- Improve the efficiency of fraud detection algorithms (e.g., reduce false positive rate).
4. Training and Support
- Conduct training sessions on FWA policies and procedures.
- Ensure high employee participation in training programs.
- Improve staff knowledge and skills through assessments.
5. Quality Assurance and Compliance
- Conduct regular audits to ensure compliance with FWA policies.
- Implement corrective actions based on audit findings.
6. Data Analysis and Reporting
- Ensure timely and accurate reporting of FWA-related data.
- Provide data-driven insights and recommendations to improve FWA management.
7. Stakeholder Communication
- Maintain effective communication with stakeholders.
- Develop and execute communication plans.
- Ensure high stakeholder satisfaction.
8. Continuous Improvement
- Implement process improvements to reduce FWA incidents.
- Promote the adoption of new FWA management practices.
Experience and qualification required
Education : Tertiary education in any field (minimum medical degree)
Experience : 3-5 years in a similar role is a must.
Skills :
- Experience with health claims and leakages
- Competent in providing medical advisory, conducting audits and improving cost- containment measures and controls
- Proficiency in using the FWA analysis tools and software including knowledge in AI and machine learning applications in fraud detection
- In depth understanding and knowledge in healthcare & clinical regulations and compliance standards related to FWA including familiarity with doctor's schedule of fees.
- Leadership, communication skills to effectively collaborate with the stakeholders
Prudential is an equal opportunity employer. We provide equality of opportunity of benefits for all who apply and who perform work for our organisation irrespective of sex, race, age, ethnic origin, educational, social and cultural background, marital status, pregnancy and maternity, religion or belief, disability or part-time / fixed-term work, or any other status protected by applicable law. We encourage the same standards from our recruitment and third-party suppliers taking into account the context of grade, job and location. We also allow for reasonable adjustments to support people with individual physical or mental health requirements.