Prudential’s 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 people’s career ambitions. We pledge to make Prudential a place where you can Connect, Grow, and Succeed.

ABOUT THE ROLE:

The role provides strategic medical and clinical support to strengthen claims governance, Fraud, Waste & Abuse (FWA) controls, DRG implementation, and cost containment initiatives. It applies medical judgment to support investigations, audit reviews, complex case assessments, and escalation handling to ensure fair, defensible, and consistent claims outcomes. The role also contributes to improving medical claims integrity, reducing leakage, supporting regulatory and provider engagements, delivering targeted training, and enhancing operational processes while upholding high standards of compliance, professionalism, and customer service.

KEY RESPONSIBILITIES:

• Provide medical and clinical input for Fraud, Waste & Abuse (FWA) and audit investigations, focusing on identification of inappropriate billing practices, unbundling, abuse patterns, and clinical inconsistencies identified through case reviews and audit findings.
• Support DRG implementation and audit reviews by assessing high‑risk or complex medical cases for medical necessity, coding accuracy, and clinical validity, including handling justified exceptions and documenting defensible medical rationales.
• Hospital discussions on strategy involving DRG, tiering and cost management strategies.
• Provide clinical input for escalated FWA, audit, and DRG matters to support governance strengthening, structured training initiatives, and targeted actions aimed at reducing claims leakage and improving medical claims integrity.
• Support cost containment strategies by providing medical insights to identify cost drivers, recommend appropriate clinical controls, support value‑based claim assessment, and contribute to initiatives that balance cost efficiency with fair and sustainable claims outcomes.
• To coordinate the complex referral requiring external expert’s opinion by consolidating information internally with the external party without disregards the compliance and regulatory rules set.
• To support any stake holders in dealing with difficult customers, reviewing and approving on complex cases to the best knowledge we can which at time may require second opinion and etc.
• Perform research to support and resolve complex claims cases, supporting development of new products, supporting management on any project and broadcast interviews or regulatory requirement to ensure our due diligent met and ensure we are upholding our business integrity in paying fair claims.
• To support the business by providing seamless customer experience for continuity of business growth and trust in building protection through prompt correspondence include meeting up with the provider as when require, and with ministry of health to obtain correct provision under which claim can be paid to be paid for consistency
• To manage Doctor Panel governance, including review and monitoring of Watch listed and Delisted doctors, and performing regular Doctor Panel audits to ensure compliance with panel standards.
• To maintain continuous professional development by updating medical, clinical, and technical knowledge to support complex referral claims requiring input.
• To design and deliver training and case studies for claims assessors to promote best practices in medical claims assessment, strengthen controls on Fraud, Waste & Abuse (FWA), and enhance cost containment through consistent and governance‑aligned claims decision‑making.
• To improve and enhance through active participation of projects on existing work process, system by rendering full collaboration to the department or to achieve stake holders to achieve more work efficiency; improve work quality, reduce error rate for cost saving in managing the claims and reduction in management of expense.
• At all times adhere to Local business & Group Regulatory Policies. Agreed & responsible on all duties assigned by the Supervisors/HOD in order to meet operational and/or other requirements 

QUALIFICATIONS & REQUIREMENTS:

Qualifications

• Degree in Medical Degree with DRG coding experience
• Other Allied Health or Health Care qualification ie: Business Administrative and Management with additional skills in Insurance, analytic will be advantage.

Experience

• Preferably having experience in providing healthcare services such as clinical evaluation, handling of patient and liaison with healthcare providers, had administrative work & resolving customer service enquiry is advantage.  
• Incumbent is requiring having at least 10 year’s experiences in insurance industry & exposure analysis & training of staffs in medical claims assessment.
• Experience in healthcare as front office or any financial institutions, i.e. Banks, Insurance will be an added advantage.

Knowledge           

• Customer service-related Life Claims or Medical Insurance.
  
  

WHY JOIN PRUDENTIAL?
At Prudential, you will be part of a purpose-led organization where your work creates meaningful impact, your growth is supported, and your contributions help shape a better future for our customers and communities.

• Meaningful work that creates a real difference.
• Continuous learning and career development opportunities.
• Collaborative and inclusive workplace.
• Opportunities to innovate, grow and make an impact.
• A culture where you can Connect, Grow, Succeed.

If you are ready to build a meaningful career would love to hear from you.

Click Apply to submit your application. Only shortlisted candidates will be contacted.

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.

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.