Head of Claim

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.

Title:  

Health Claim Section Head

Location:

Jakarta – PLA Head Office

Job Scope:    

• Lead and Manage the health claims department, overseeing both cashless and reimbursement processes. Primary responsibility is to ensure efficient and accurate claims processing while maintaining high customer satisfaction.
• Managing claim management function, which includes claims queries and complaints handling, claims audit and investigation. The expected outcome is a solid construction and sustainable development of operations, claims, system management and PRUhospital network to support the day to day health business under Health Business.

Principle Duties & Responsibilities:

• Strategy and Leadership:
  • Develop and execute the overall claims strategy, aligning it with organizational goals.
  • Lead and mentor a team of claims professionals, ensuring optimal performance.
  • Collaborate with other departments (such as underwriting, customer service, and legal) to enhance claims processes.
• Cashless Claims Management:
  • Oversee the cashless claims process, including pre-authorization, network coordination, and direct billing
  • Ensure timely approvals and seamless hospitalization experiences for policyholders.
  • Monitor claim trends, identify areas for improvement, and implement process enhancements.
  • managing business processing with hospitals/clinics related with admission and discharge – in patient & out patient, letter of guarantee issuance, claims processing for reimbursement and cashless, suspend tracking & monitoring, monitoring SOP and conduct analytics study on delivery & performance review process – in patient (admission and discharge) & out patient
  • acquire and develop relationship with hospital and clinic providers and support Operations team in responding to inquiries from providers, monitoring SOP and conduct regular Quality Check on clinics/hospital providers pertaining their SLA and other agreed services to PLA clients (B2B and B2C)
• Reimbursement Claims Oversight:
  • Manage the reimbursement claims process, from claim submission to settlement.
  • Review and approve reimbursement requests, ensuring compliance with policy terms.
  • Address claim disputes and negotiate settlements when necessary.
• Quality Assurance and Compliance:
  • Implement quality control measures to minimize errors and enhance claims accuracy.
  • Stay updated on industry regulations, compliance requirements, and best practices.
  • Conduct audits and internal reviews to maintain high standards.
• Customer Relations:
  • Handle escalated customer inquiries related to claims.
  • Collaborate with customer service teams to address policyholder concerns promptly.

• Reporting and Analytics:
  • Generate reports on claims performance, trends, and key metrics.
  • Use data insights to drive operational improvements

Job Specification:

Qualification

• Bachelor’s degree in a relevant field (such as insurance, healthcare management, or business administration).
• Proven experience in health claims management, including both cashless and reimbursement processes.
• Strong leadership skills, decision-making abilities, and problem-solving capabilities.
• Excellent communication and negotiation skills.
• Familiarity with medical coding, insurance regulations, and industry standards.

Experience

• Minimum 10 years relevant experience, most preferably in health business and medical services/TPA related function.
• Candidate should have earned experience in implementing new initiatives/projects pertaining operations, claims management and hospital network function in health business or TPA organisation

Knowledge

• Comprehensive understanding of:

• Trends and analysis in health business & medical services relevant to life insurance industry
• General operations, claims and business process of health business/TPA organisation
• Life and health insurance products and TPA services
• Regulations relevant to life and health insurance business including customer protection

• Skill
• Experience in handling senior level management and various health services/hospital providers.
• Excellent in negotiation and partnership relations skill
• Excellent in interpersonal and communication skill.
• Capable of working in a fast paced environment.
• Proficient in English
• Proficient in MS Office

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.