Key Responsibilities & Accountabilities
• Develop and maintain a comprehensive understanding of insurance operational guidelines, standard operating procedures (SOPs), policy terms, and legal frameworks.
• Acquire technical proficiency to effectively manage system-related issues, including bug reporting and outage resolution.
• Rigorously validate medical request documentation submitted via ticketing or online systems.
• Adhering to established operational guidelines and SOPs.
• Accurately input request data into the system, ensuring thorough database maintenance and documentation prior to decision-making.
• Thoroughly assess medical requests, gathering all necessary information
to support informed decision-making.
• Suspend requests requiring further investigation and resolve them within quality standards.
• Proactively identify fraudulent request patterns, flag suspicious cases for investigation, and report wasteful practices to relevant departments.
• Respond to inquiries and requests from internal departments, including Customer Service, Client Relations, Claims, Fraud Waste & Abuse, Sales, and Complaints, within authorized boundaries and department guidelines.
• Collaborate with other departments to resolve complex requests and propose solutions to prevent recurrence.
• Maintain flexibility to work
shifts as determined by supervisors and managers to align with capacity planning and operational needs.
• Maintain full compliance of department to AXA standards and reactivity/contribution to all compliance processes.
Job Specifications
Education / Certification
• Bachelor of pharmaceutical sciences
• 0-3 Year of Experience
Soft Skills & Behavioral Competencies
• Pharmaceutical Practice / Medical Practice.
• Strong interpersonal and customer service orientation.
• Proficiency in computer applications.
• Ability to multitask and prioritize tasks effectively.
• Strong problem-solving and decision-making skills.
• Attention to detail and accuracy.
• Knowledge of insurance products and processes (preferred)
