Advisor – Claim Operations

4 weeks ago

Melbourne, Victoria, Australia Cognizant Full time

Get AI-powered advice on this job and more exclusive features.

  • Process health insurance claims in accordance with Insurance Authority (IA) regulations.
  • Verify policyholder eligibility and coverage details before claim adjudication.
  • Service and resolve inquiries from customers, members, beneficiaries, and others regarding Health Care products and benefits across multiple product lines
  • Ability to communicate effectively across multiple channels, including phone, e-mail, chat, and text
  • Ability to succinctly collect information from a customer to set up a new claim
  • Ability to gather information from multiple source systems to understand and articulate the status of a claim – and what information may be needed, next steps in processing, etc.
  • Ensure accurate data entry and documentation of claim details in the system.
  • Coordinate with healthcare providers to validate treatment and billing information.
  • Identify and escalate potential fraud or abuse cases to the compliance team.
  • Maintain turnaround time (TAT) and service level agreements (SLAs) for claims processing.
  • Respond to internal queries related to claim status and documentation.
  • Ensure compliance with internal SOPs and regulatory standards.
  • Support audits by providing required documentation and clarifications.
  • Participate in training sessions on regulatory updates and system enhancements.
  • Maintain confidentiality and data privacy in handling sensitive health information.
  • Collaborate with customer service teams to resolve member inquiries.

Academic and Additional Qualifications Needed:

  • Bachelor's degree in Insurance, Healthcare Administration, or related field.
  • 1–3 years of experience in health insurance claims processing.
  • Basic understanding of health insurance regulatory framework.
  • Proficiency in claims processing systems and MS Office tools.
  • Fluency in Mandarin, Cantonese, and English (speak, read, and write).
Seniority level
  • Seniority levelAssociate
Employment type
  • Employment typeContract
Job function
  • Job functionInformation Technology
  • IndustriesIT Services and IT Consulting

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