Sr. Specialist - Medical Underwriting

Nice to know

Being responsible for Pre-authorization process here are 2 parts which are pre-arrangement part (pre-approve for procedure/surgery) and admission part (initial approval for admission). We service both providers and members each day as shift work from 8 am - 5 pm every day. We pay more attention both to medical necessity and cost containment to control the treatment cost in a procedure which the providers have the package price. These processes make the customers have good benefit management under customary price and our business get more cost saving.

Your Day at Allianz Ayudhya

1) Reviews of claims and medical reports (medical indication assessment)

• Verify the eligibility of the claim by using and applying medical knowledge to pre-arrangement cases.
• In case of medical issues such as medical necessity for the procedures have to consult medical consultant team.
• Applies all medical necessity guidelines (Thai Medical Practice Guidelines), determine coverage and apply all cost containment measures.
• Sending the criteria checklist to consultant doctor and benchmark price & LOS comparison.
• The conclusion and issuing the confirmation letter to the providers within SLA (3 days)
• Control the cost-effectiveness of medical care and ensure that any new clinical procedures, drugs or technology are appropriate and safe for our customers.
• Study and understand A&H policy & coverage to apply pre-arrangement and admission part.
• Coordinate with Internal teams such as corporate key accounts, care coordinator, medical team, and External team such as utilization nurses from the hospital.

2) Collaboration process with Health Concierge, Health Solutions & Care Coordination team step as below.

• Screening the case which meets the criteria for collaboration project or package.
• Sending the criteria checklist to consultant doctor.
• Benchmark price & LOS comparison.
• Package price checking of each provider.
• Provider negotiation.

3) Detects suspicious, fraud or abuse claim by providers and refer to Clinical Governance Team.

4) Process Coding (ICD codes) based on medical procedures and the claim process.

Must Have

• Bachelor's degree in Nurse Science or related field
• Minimum 3 years in nursing experience
• Nurse in critical units such as ER, ICU, OR will be an advantage
• Knowledge of claims management
• Experience in insurance related topics: health

Nice to Have

• Able to work in commercial environment and fast-moving business.
• Customer relation management
• Excellent interpersonal and communication skills.
• Experience handling and managing all aspects of the relationships with the customer
• 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.

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