Senior Manager, Pre-authorisation & Claims Servicing

Prudentials purpose is to be partners for every life and protectors for every future. Our purpose encourages everything we do by creating a culture in which diversity is celebrated and inclusion assured for our people customers and partners. We provide a platform for our people to do their best work and make an impact to the business and we support our peoples career ambitions. We pledge to make Prudential a place where you can Connect Grow and Succeed.

Pre-Authorisation & Claims Operations Management

• Supervise pre-authorisation and cashless/reimbursement minor claims operations including but not limited to:

• Monitoring key performance indicators (KPIs) such as new pre-authorisations pending claims escalations appeals complaints and enquiries

• Ensuring the quality of pre-authorisation and claims decisions made by both internal teams and vendors

• Conducting instant case assessments to determine member eligibility treatment validity medical necessity appropriateness of care and reasonable or customary charges

• Negotiating procedure and service fees with both network and non-network medical providers where appropriate

• Fostering strong relationships and streamlining administrative processes between pre-approval functions and cashless arrangements with medical network providers

• Establishing and regularly updating Pre-Authorisation Claims Policies and Guidelines

• Reviewing authority levels for pre-authorisation claims assessors

• Addressing escalated disputes related to pre-authorisation or cashless/reimbursement minor claims

• Managing pending pre-authorisation and cashless claims to ensure they remain at acceptable levels

• Ensuring all pre-authorisation and cashless/reimbursement minor claims are handled promptly

• Provide ongoing training and development opportunities for both in-house teams and vendors

• Lead claims-related projects such as Claims Propensity and eClaims in relation to pre-authorisation and cashless claims

• Oversee claims analytics to monitor trends in pre-authorisation and cashless claims

• Plan and implement innovative transformative initiatives for continuous improvement within pre-authorisation and cashless claims management

Compile management reports on routine claims statistics and emerging claims trends provide proactive recommendations and oversee the effective implementation of procedures to mitigate claims abuse. Participate in departmental and company projects as required. Offer expert claims support for product development enhancement initiatives and the drafting of annexures.

Risk and Fraud Management

Manage Fraud abuse and wastage Pre-authorization claims /cashless and reimbursement minor Claims Risk Management Stay close to advance medical treatment trend medical expenses regulatory changes & market news and work ahead of those changes with constructive preventive measures options and solutions.

Collaborate with all departments and executives to oversee the delivery of fast responses and actions for Minor complaints customer issues and regulatory requirements to maintain the companys strong brand reputation.

Prudential is an equal opportunity employer. We provide equality of opportunity of benefits for all who apply and who perform work for our organisation irrespective of sex race age ethnic origin educational social and cultural background marital status pregnancy and maternity religion or belief disability or part-time / fixed-term work or any other status protected by applicable law. We encourage the same standards from our recruitment and third-party suppliers taking into account the context of grade job and location. We also allow for reasonable adjustments to support people with individual physical or mental health requirements.