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 incumbent is responsible for leading and governing the end-to-end healthcare claims assessment function, ensuring alignment with company policies, operational standards, and regulatory requirements. This includes overseeing claims adjudication processes, quality assurance, risk management, and service delivery performance across both reimbursement and direct billing claims.
The role drives collaboration with internal and external stakeholders, to enhance claims quality, control costs, and improve customer experience. The incumbent is also accountable for managing team performance, driving continuous improvement initiatives, and ensuring compliance with audit and risk frameworks to support the company’s healthcare business growth.
Job Description
Lead and oversee daily healthcare claims operations, ensuring timely adjudication in compliance with Operating Manual, SLA, and quality standards.
Govern claims assessment processes across reimbursement and direct billing, including complex case review, escalation handling, and decision oversight.
Ensure effective implementation of quality assurance and audit frameworks (internal audit, QA, SOX/GwIA), maintaining high standards of claims accuracy and compliance.
Act as the key liaison between Claims and cross-functional stakeholders (TPA, medical providers, Product, System, Risk, Finance) to resolve operational issues and improve claims processes.
Drive cost control and risk management initiatives, including monitoring fraud, waste, and abuse (FWA), ensuring medical necessity and appropriate treatment evaluation.
Oversee claims system utilization and improvement, ensuring accurate data capture, system updates, and alignment with automation initiatives.
Lead communication and engagement with external stakeholders, including hospitals and TPA, to manage claims-related matters, disputes, and service quality issues.
Drive continuous improvement projects to enhance productivity, turnaround time, and customer experience in claims servicing.
Manage team performance, including resource planning, training, coaching, and performance monitoring to ensure consistent delivery of service excellence.
Prepare and review reports on claims performance, quality metrics, and risk indicators for management decision-making.
Job Accountability
The incumbent leads and governs the healthcare claims assessment function, ensuring quality, SLA adherence, and compliance with company and regulatory standards.
The role drives collaboration with internal stakeholders and external partners to identify risks, monitor fraud and abuse trends, and enhance claims effectiveness.
The incumbent oversees complex adjudication, quality assurance, and cost control, while driving continuous improvement to strengthen operational efficiency and customer experience.
Job Requirements
a. Qualification
Degree in Biomedical Science, Allied Health, Economics, Business Administrative, Business Management, and etc.
b. Experience
Preferably experience in healthcare and/or claims, i.e. customer Service, HealthCare claims department or Hospital environment will be required.
Working at an insurance company or banking at managerial level for at least 5 years.
c. Knowledge, Skills & Attributes
Insurance/Legal/Health management and project management,
Possess knowledge on Life Insurance claims processing.
Computer literate and familiar with MS Excel, MS Word & MS PowerPoint...
Self-assured and results oriented
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.