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Senior Officer, Claims (50000271)
TP. Ha Noi, VNPosted 2 weeks ago
onsite
Job Description
Job Purpose
Plays a critical role in executing high-quality claims operations, providing technical expertise for complex cases, ensuring procedural transparency and regulatory compliance, and working closely with cross-functional teams to deliver a customer-centric claims experience.
Key Accountabilities (1)
1. Technical Claims Operations
- Perform technical assessments of complex claims, including death benefits, critical illness, accident coverage, and waiver-of-premium cases, with thorough review of policy terms and supporting documents.
- Validate key documents such as medical records, death certificates, accident reports, and legal statements, ensuring compliance with the benefit conditions.
- Identify exclusions, disputes, or risk indicators within claims files and recommend resolution strategies or escalation actions when appropriate.
- Collaborate with the medical review unit to interpret complex health records or lab results that may impact payout decisions.
- Serve as an internal quality reviewer (peer reviewer) for cases flagged for potential fraud, discrepancies, or requiring in-depth evaluation.
- Provide technical guidance to junior staff and peers on handling special cases or incorporating updated product or policy criteria.
- Work jointly with Legal to assess claims involving beneficiary disputes, fraud risk, or confidentiality restrictions.
- Track operational KPIs such as average turnaround time, supplemental documentation requests, and rejection rates, offering insights to optimize performance and reduce complaints.
- Propose enhancements to forms, evaluation checklists, and expert commentary frameworks to streamline decision-making and improve accuracy.
- Draft professional, transparent customer and agent correspondence for cases requiring clarification, additional verification, or declined outcomes, aligning with company policies.
- Support data reconciliation efforts between paper documentation and system entries, ensuring consistency for internal audit and reinsurance purposes.
- Maintain secure records and contribute to internal case libraries by documenting notable technical issues and best practices for team reference and training.
Key Accountabilities (2)
2. Internal Collaboration
- Collaborate effectively with departments such as Underwriting, Product, Customer Service, IT, and Legal to resolve complex cases with consistent and aligned information flow.
- Serve as a subject-matter contact point for non-technical departments (e.g. Sales, Customer Service) when claims-related inquiries arise involving benefit eligibility, resolution mechanics, or legal obligations.
- Join recurring technical meetings with management and cross-functional teams to share updates, analyze case examples, and contribute specialist insights to workflow enhancement.
- Support the creation of internal reference documents, including guides for exceptional cases, response templates, and claims evaluation checklists.
- Participate in testing new tools (evaluation systems, claims software), providing feedback based on daily operational experience to improve usability and reliability.
- Offer ideas to simplify coordination steps across departments, especially in document handover, internal approvals, and customer data verification processes.
- Mentor and assist junior or less-experienced staff in handling specialized claims cases, strengthening overall team capabilities.
- Actively maintain and grow technical expertise through internal documentation, knowledge-sharing sessions, recurring training, and exposure to process optimization initiatives.
- Join internal innovation teams focused on streamlining workflows, strengthening document handling, and delivering superior claimant experience.
- Help nurture a professional and collaborative working environment that encourages learning, sharing, and personal growth within the Claims team.
Key Accountabilities (3)
3. Quality control and process improvement
- Conduct periodic reviews of processed claims to ensure procedural compliance, document completeness, and accuracy in applying benefit terms, particularly in complex or sensitive cases.
- Analyze common processing errors or discrepancies to identify root causes and recommend corrective actions to minimize recurrence.
- Recommend updates to technical checklists, instructional templates, and case triage workflows to promote clarity, consistency, and reduce systemic missteps.
- Assist management in compiling quality control data, identifying operational trends, and preparing periodic reports for internal reviews or external audits.
- Contribute to the development of product-specific evaluation guides, categorizing claims by benefit type and risk level to promote specialized case handling.
- Participate in internal peer audits across claims teams to harmonize processing standards and ensure consistent quality across functions.
- Propose implementation of technologies such as automated alerts for missing documents, dashboard-based risk data analysis, and integration with external verification APIs.
- Monitor customer feedback related to transparency, resolution time, and service response quality, and suggest enhancements to meet evolving service expectations
- Share real-world claims handling examples in improvement workshops and offer professional perspectives to challenge or refine proposed workflows.
- Collaborate with claims system developers to recommend UI adjustments, improve record retrieval features, or add approval support tools.
- Support onboarding and internal training programs focused on quality assurance, educating peers on error identification and correct procedural application.
- Promote a team-wide quality culture through sustained accuracy, peer-to-peer review practices, and constructive feedback loops.
Key Relationships - Direct Manager
Manager/Senior Manager/Senior Expert, Claims Handling
Key Relationships - Direct Reports
Key Relationships - Internal Stakeholders
Internal function Division in company
Key Relationships - External Stakeholders
Policyholders/beneficiaries, insurance agents, medical assessors, and legal documentation providers.
Success Profile - Qualification and Experiences
Bachelor’s degree in Insurance, Finance, Economics, Business Administration or a related field.
Minimum of 5 years of experience in claims processing, preferably in life insurance or large financial institutions. Strong understanding of claims procedures, life insurance product lines, and relevant legal frameworks. Proficient in reviewing and analyzing medical records, insurance policies, and accompanying legal documents. Effective internal and customer communication skills, with agile problem-solving and adherence to transparency standards.