Manager - Medical Claims at Great Eastern Life Assurance Co Ltd

Cuenca, Azuay, Ecuador -

Full Time

Start Date

Immediate

Expiry Date

20 Sep, 26

Salary

0.0

Posted On

22 Jun, 26

Experience

5 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Claims Assessment, Medical Knowledge, Analytical Skills, Stakeholder Engagement, Customer Service, Process Improvement, Regulatory Compliance, Risk Management, ICD/CPT Codes, Medical Documentation Review

Industry

Insurance

Description

Are you passionate about making a meaningful impact in healthcare insurance space? At Great Eastern, we’re redefining what it means to be a claim professional. Join a passionate team where your medical knowledge, analytical skills, and attention to detail will directly impact the lives of our customers and the future of health insurance. You’ll play a vital role in ensuring our policyholders receive timely and accurate support when they need it most. You’ll also be empowered to contribute to service excellence initiatives that enhance the overall claims experience. It’s a career path that builds deep expertise in claims assessment and customer care. 1. Claims Assessment & Decision Making Assess integrated shield claims and appeals accurately and within established service standards to ensure timely and correct claim payments. Manage claim investigations and appeals, including reviewing medical documentation and policy terms. Conduct review of pending claim to ensure reserve adequacy and closure of claims in a timely manner. Identify claim patterns and unusual or inappropriate practices and recommend improvements to strengthen claims controls and streamline claim processes. 2. Stakeholder & Customer Engagement Collaborate with medical institutions, policyholders, and internal stakeholders to gather and clarify clinical information or outstanding requirements. Deliver high standards of customer service and strengthen relationships with customers and distribution channels. 3. Drive Service Excellence & Process Improvement Deliver accurate and timely assessment of medical claims, ensuring fair payouts in line with our service standards and adherence to policy terms. Provide clear, empathetic communication timely to policyholders, medical professionals, and internal stakeholders, making the claims process smooth and transparent. Participate in claims process reviews, system enhancements, and service excellence initiatives to improve efficiency, controls, and customer experience. 4. Ensure Compliance Adhere to internal policies and external regulatory requirements to maintain integrity and trust in our claims operations. Take accountability in considering business and regulatory compliance risks and takes appropriate steps to mitigate the risks. Maintain awareness of industry trends on regulatory compliance, emerging threats and appropriate steps to mitigate the risks. Highlight any potential concerns/risks and proactively shares best risk management practices. • Bachelor’s degree or Professional Insurance Certificate or a related insurance or healthcare discipline • At least 5 years of experience in relevant claims processing experience • Strong grasp of medical practices, terminology, ICD/CPT codes, and insurance policy terms • Strong analytical skills with ability to interpret complex medical data, spot trends, and make sound decisions under pressure • Detail-oriented with a proven track record of managing high processing volumes without compromising quality • Customer-focused and excellent at building relationships with stakeholders and delivering clear, empathetic communication • Team players; are eager to learn and grow in a fast-paced, collaborative environment that values innovation and service excellence.

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Responsibilities

Manage the assessment and decision-making process for integrated shield medical claims and appeals while ensuring adherence to policy terms. Collaborate with medical institutions and internal stakeholders to drive service excellence and maintain regulatory compliance.