Oliver James Executive are seeking a seasoned Lead / Director of Claims to oversee business-as-usual (BAU) claims operations across Group and Individual Life & Health businesses, covering both reimbursement and cashless/pre-authorization (PA) processes.
In this leadership role, you will be accountable for handling complex escalated cases, managing risk and Fraud, Waste & Abuse (FWA) activities, driving service excellence, and supporting distribution channels.
Key Responsibilities
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Claims Operations Leadership: Oversee end-to-end claims operations across reimbursement and cashless processes to ensure fair, efficient, and transparent claims handling.
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Complex Cases & Complaints Management: Collaborate with stakeholders to manage complex cases, complaints, and appeals, ensuring smooth professional resolution and regulatory compliance.
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Risk Management & FWA: Strengthen risk-based assessment frameworks with a focus on higher-risk and FWA-suspected cases, working closely with the Claims Risk Manager and Chief Medical Officer.
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Continuous Improvement: Monitor operational performance, enhance workflows, update procedural manuals, and co-develop improvement actions with customer service to elevate the overall claims experience and NPS.
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People Leadership: Train and mentor claims assessors on new or revised guidelines, leading remote teams and working independently under tight schedules.
What We Are Looking For
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Education: Degree holder or above.
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Experience: At least 10 years of claims experience in Individual and/or Group Life & Health business. Experience in FWA management, complaints handling, and regulatory interactions is strongly preferred.
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Technical Knowledge: Proficient knowledge of insurance products and regulatory requirements (e.g., AML, FATCA, CRS, local insurance regulations).
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Skills: Excellent interpersonal, stakeholder management, conflict resolution, analytical, and problem-solving skills.
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Communication & Software: Good command of English, Chinese, and Mandarin (spoken and written), alongside proficiency in MS Office suite and Chinese Word Processing.
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Preferred Credentials: Professional insurance qualifications such as FLMI.
