Job Description

Medical/Regulatory Oversight

- Serve as Clinical Governance Officer (CGO) for all clinics

- Lead audit preparation and execution to ensure regulatory compliance

- Act as the ordering doctor for laboratory and imaging tests, including prompt responses to critical results

- Address general medical regulations queries from internal and external stakeholders

- Lead initiatives to manage and reduce the cost of medical claims through clinical review, provider negotiation, and strategic interventions.

- Conduct and oversee claims audits, identifying patterns of overutilization or fraud, waste, and abuse (FWA).

- Monitor provider performance and billing behavior to identify and mitigate fraud, waste, and abuse (FWA); initiate corrective actions where necessary.

- Develop internal cost containment SOPs and workflows in collaboration with operational teams to streamline claims processing and medical adjudication.

- Act as the primary client-facing representative for all matters related to medical cost containment.

- Prepare regular reports and presentations for leadership and clients, highlighting key cost drivers, trends, and opportunities for optimization.

Clinical Support

- Review Patient Information Leaflets (PIL)

- Perform regular medication reviews and sign off for VIP, ensuring safe and effective treatment plans

Claims, LOG and Pre-Authorization

- Act as the final medical escalation point for claims, LOG, and pre-authorization within the company

- Develop and refine general guidelines and definitions for medical reimbursable claims

- Provide strategic support to the Claims and LOG teams in developing and enhancing STP workflows and overall process improvements

Business Development Support

- Participate in presentations and stakeholder engagement as a clinical representative

- Collaborate on workflow reviews to align clinical operations with BD initiatives

- Contribute to the ongoing refinement of company's data analytics, offering client insights and actionable strategies.

- Provide KIV support for on-site rollout of services

- Participation in initiative-based projects as required, including clinical input and representation in BD-related presentations and discussions

- Chronic disease management program- Involvement in design, execution, and evaluation

- LPA program- Support for program rollout and medical compliance

Job Requirements

• Medical Degree from a recognized university (MD or MBBS preferred)
• Minimum 5 years of relevant experience in TPA or insurance company
• Willingness to support after-office-hours remotely
• Willing to travel (Singapore)

Skills