Sr. Specialist - Hospital & Claim Audit (Health Insurance)

Job Summary:

The position holder is responsible to ensure providers are providing the best possible treatment for Allianz and price guidelines with high levels of quality based clinical outcomes

Key Responsibilities:

Clinical Quality

• Develop and implement a clinical quality strategy, which assures our members that they are receiving high quality and appropriate care.
• Ensure that all treatment and care given to our members including admission to hospital is appropriate and in accordance with agreed protocols.
• Encourage clinical best practice by providing analytical feedback hospitals, clinics and doctors on clinical practice including procedural costs, length of stays and outcomes.
• Ensure that all hospitals and clinics in our network meet our standards of care and take necessary action when the care given is below standard.
• Ensure that any new clinical procedures, drugs or technology are appropriate and safe for our customers
• To review and manage the treatment of high claiming members to ensure that their treatment is appropriate

Clinical Audit

• Carry out clinical audits on both provider network and non-provider network, ensuring that Allianz customer receive high quality and appropriate treatment and care at an affordable price.
• Retrospective review (Internal and External Audit).

Clinical Governance scheme

• Attend the pool insurance meeting as schedule Attend claim and clinical committee as team member

Must Have

• Bachelor’s or master’s degree in Nurse Science
• At Least 3-5 yrs of experience in Nurse in hospital and insurance industry experience will be advance
• Understanding of insurance databases
• Experience in data collection, evaluation, and interpretation
• Experience in data analysis and data visualization tools (e.g. PowerBI, Tableau)
• Knowledge of collaborative project management tools (e.g. Trello, JIRA, Asana)
• Knowledge of Microsoft Office suite, Microsoft EPM, and MS Outlook
• Any AI-future skills e.g., ChatGPT, or CoPilot365, will be 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.