Specialist - Claim Direct (Reimbursement)

Role Overview

The Specialist – Claim Reimbursement is responsible for supporting end‑to‑end claims assessment for reimbursement and OPD cashless claims. This role ensures timely, accurate, and compliant claim decisions, manages complex cases, monitors pending workloads, and collaborates with internal stakeholders to uphold operational standards and service excellence.

Key Responsibilities

1) Claims Reimbursement

• Support the team in investigating and making claim assessment decisions.
• Approve claim payments in accordance with authorization limits.
• Perform claim rejection when criteria are not met.
• Request additional information or documentation when required.
• Issue memos in the system to support administrative processing.
• Submit cases for further investigation when necessary.
• Request hospital medical records to support claim review.
• Continuously monitor, review, and make decisions on pending or backlogged reimbursement cases.
• Consolidate complex cases and prepare documentation for Claim Committee and COO/CEO for decision‑making based on authorization guidelines.

2) Hospital Assessment – OPD Cashless

• Handle OPD cashless claims submitted by hospitals.
• Perform investigation and make claim decisions for OPD cashless cases in the system.
• Approve claim payments according to authorization levels.
• Perform rejection for fax‑submitted claims when applicable.
• Request additional information as needed to complete assessment.
• Issue memos in the system for administrative follow‑up.
• Submit cases for further investigation when necessary.
• Request hospital records and supporting documents.
• Monitor and decide on pending OPD cashless cases and backlog items.
• Manage and present complex OPD cashless cases requiring Claim Committee decisions.
• Ensure claim approvals are accurate, timely, and aligned with service-level agreements (SLAs).

Must Have Qualifications

• Bachelor’s degree in Nursing Science, Medical Technology, or related field.
• Minimum 3 years of experience as a Claims Assessor or in relevant functions within the insurance industry.
• Strong knowledge and understanding of nursing/medical concepts, insurance claim regulations, policies, and guidelines.

Nice to Have

• Strong attention to accuracy and detail.
• Experience in claims or CRM systems.
• Ability to prioritize claim‑related tasks efficiently.
• Proficiency in MS Office, especially Advanced Excel, PowerPoint, Power BI, and other data software tools.
• Familiarity with AI‑related tools (e.g., ChatGPT, Microsoft Copilot 365) is an advantage.

Allianz Group is one of the most trusted insurance and asset management companies in the world. Caring for our employees, their ambitions, dreams and challenges is what makes us a unique employer. We are united by a shared commitment: to put our customers first and at the centre of everything we do. Their needs inspire our thinking and guide our actions. Together, we can build an environment where everyone feels empowered and confident to explore, grow and shape a better future – for our customers and for the world around us. At Allianz, we stand for unity: we believe that a united world is a more prosperous world, and we are dedicated to consistently advocating for equal opportunities for all. The foundation for this is our inclusive workplace, where people and performance both matter, and where integrity, fairness, inclusion and trust are at the heart of our culture. We therefore welcome applications regardless of ethnicity or cultural Internal background, age, gender, nationality, religion, social class, disability or sexual orientation, or any other characteristics protected under applicable local laws and regulations.

Join us. Let's care for tomorrow.