Pre-Authorization - Health Insurance (Hong Kong)
Processor RoleJob Responsibilities and Expectations
- Review and validate pre-authorization requests for medical services and procedures.
- Ensure completeness of documentation submitted by policyholders and healthcare providers.
- Verify eligibility and coverage based on policy terms and conditions.
- Coordinate with internal claims and underwriting teams for complex cases.
- Input and update pre-authorization decisions in the claims management system.
- Communicate authorization outcomes to providers and insured members.
- Ensure compliance with Hong Kongs Insurance Authority (IA) regulations and internal SOPs.
- Identify and escalate potential fraud or abuse cases to the compliance team.
- Maintain turnaround time (TAT) and service level agreements (SLAs).
- Support audits and quality checks by providing accurate documentation.
- Participate in training sessions to stay updated on regulatory changes.
- Handle sensitive medical information with strict confidentiality.
- 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 claim and what information may be needed, next steps in processing, etc.
Academic and Additional Qualifications Needed
- Bachelors degree in Nursing, Health Sciences, Insurance, or related field.
- Basic understanding of medical terminology and health insurance policies.
- Familiarity with Hong Kongs healthcare system and insurance regulations.
- Strong attention to detail and data entry accuracy.
Quality Review Role
Job Responsibilities and Expectations
- Conduct quality audits of pre-authorization decisions and documentation.
- Ensure adherence to regulatory standards and internal guidelines.
- Identify trends in errors and recommend corrective actions.
- Collaborate with processors to provide feedback and training support.
- Maintain audit logs and prepare quality performance reports.
- Support compliance reviews and regulatory inspections.
- Ensure consistency in decision-making across the team.
- Assist in updating SOPs based on audit findings and regulatory updates.
- Participate in cross-functional meetings to improve process efficiency.
- Monitor turnaround times and recommend process improvements.
- Ensure accurate classification of medical procedures and services.
- Maintain confidentiality of patient and policyholder information.
Academic and Additional Qualifications Needed
- Bachelors degree in Nursing, Health Administration, or Insurance.
- 35 years of experience in health insurance or medical claims review.
- Knowledge of Hong Kongs Insurance Authority (IA) compliance standards.
- Certification in medical coding or auditing is an advantage.
Supervisor Role
Job Responsibilities and Expectations
- Supervise daily operations of the pre-authorization team.
- Allocate workload and monitor team performance against SLAs.
- Resolve escalated cases and provide guidance on complex authorizations.
- Ensure compliance with IA regulations and internal audit requirements.
- Conduct performance reviews and support staff development.
- Coordinate with provider relations and claims teams for seamless service.
- Implement process improvements to enhance efficiency and accuracy.
- Monitor regulatory updates and ensure team readiness.
- Prepare operational reports and present to senior management.
- Support system enhancements and user acceptance testing (UAT).
- Ensure high levels of customer satisfaction and service quality.
- Maintain a culture of compliance, integrity, and continuous improvement.
Academic and Additional Qualifications Needed
- Bachelors degree in Health Sciences, Insurance, or Business Administration.
- 58 years of experience in health insurance operations, with supervisory exposure.
- Strong knowledge of Hong Kongs health insurance regulatory framework.
- Leadership and team management skills with a focus on service excellence.
Manager Role
Job Responsibilities and Expectations
- Lead the strategic planning and execution of pre-authorization operations.
- Ensure compliance with Hong Kongs Insurance Authority (IA) and industry best practices.
- Develop and implement policies, procedures, and quality standards.
- Manage budgets, staffing, and resource planning for the department.
- Liaise with regulators, reinsurers, and healthcare networks as needed.
- Drive digital transformation and automation initiatives.
- Monitor KPIs and implement corrective actions for performance gaps.
- Represent the function in cross-departmental and executive meetings.
- Ensure business continuity and risk mitigation strategies are in place.
- Mentor and develop leadership pipeline within the team.
- Oversee vendor relationships and service level compliance.
- Champion a customer-centric and compliant operational culture.
Academic and Additional Qualifications Needed
- Bachelors or Masters degree in Health Administration, Insurance, or Business.
- 10+ years of experience in health insurance operations, with managerial experience.
- Strong understanding of Hong Kongs insurance regulatory landscape.
- Proven leadership in managing large teams and operational transformation.
Valid PAN Number - _____________________(Why PAN Required > Mandatory to Process Candidature & Find Duplicity in Internal PAN Validation Process and also to initiate a screening call.
Please reach out in case of any queries.
Sonali Chattopadhyay I Associate People Success
