Abdul Hadi Bin Ros

Medical Health Insurance Claims Analyst
  • Member Since, 6 February 2019
  • Experience 10 - 20 Years
  • Range Age 36 - 40 Years
  • Age (Years) 36
  • Expected Salary (RM) More 5,000
  • Languages English, Malay
  • Highest Education Levels Degree
To obtain a Medical Claims Analyst position where I can enhanced my skills in evaluating Life, Health & Accident claims submitted which would help resolving disputes and maintaining good relationships between clients, servicing agents, company and government bodies and at the same time making positive contributions to the company.

Education

  • Bachelor Degree of Decision Science with Honours
    2002 - 2005 Universiti Utara Malaysia

    MAJOR SUBJECTSDiscrete MathematicsStatistical Distribution TheoremLinear AlgebraDecision Making Science I, II, III & IVBusiness & Managerial StatisticsCalculus I, II, III & IVComputer Modelling In BusinessMultiple Regression Analysis In Business ApplicationHeuristic TechniquesBayesian Decision TheoremBusiness Experimental DesignStatistical Quality ControlProject ManagementAdvanced Data AnalysisBusiness ForecastingResearch MethodsRisk Management

  • Sijil Pelajaran Malaysia
    1999 - 2000 Sekolah Menengah Sains Muar, Johor

Work Experience

  • 01-04-2010 - 11-07-2018
    Assistant Manager, Medical Business Management / Claims Department

    1. Conducted / Evaluated and performed necessary investigations of medical/life claims referred by Hospital Alliance Services, Pay-and-File Claims and/or referred by internal and external parties.

    a) Policy and/or Endorsement within contestable period (commencement date and revival date) in order to establish Non Disclosure Material Facts that might warrant current terms and conditions of the policy to be reviewed and revised.

    b) Policy and/or Endorsement beyond contestable period (commencement date and revival date) in order to establish Pre-Existing Conditions Clause and/or Fraud.

    2. Reviewed medical records and claims data and subsequently plan case management.

    3. Coordinated with internal parties to collect data and implemented the revised terms and conditions once the investigation has been finalized.

    4. Gathered substantial evidence to prove Non Disclosure and/or Fraud and provided case summaries and recommendation to higher management for further action.

    5. Provided necessary information for enquiries receive via ICVS, LIAM, PIAM and other insurance companies.

    6. Provided case summary and explanation to FMB/OFS and Bank Negara Malaysia.

    7. Involved in-depth discussion and provide review and feedback for various medical claims riders/products prior to launch.

    8. Reviewed and approved cases that exceeded subordinates authority within the required benchmarks.

    9. Trained new joiners on claims processing rule and products knowledge including Review and Feedback for the On-The-Job training cases.

    10. Trained other claims analyst in order to grant and upgrade authority limit.

    11. Assisted supervisor to provide weekly error claim report to claims assessors on the error and provide coaching if required.

    12. Assisted supervisor to conduct regular claims review in claims performance to ensure claims principles/authorities are adhered to. Review claims decision making process to identify areas of claims risk management concerns for further improvements.

    13. Analyzed each Medical Overseas Treatment Claims to ensure that they followed proper guidelines and procedures.

    14. Attended and resolved complaints / enquiries receive through emails and calls and subsequently provide clear explanation.

    15. Involved in Claims Roadshow nationwide to provide better understanding to the servicing agents.

    16. Involved as Business Analyst / Tester role as Person-In-Charge for Claims Department on project basis in relation of Life & Medical Insurance (professional), Group Insurance (basic) and General Insurance (basic).

    a) Prepared and developed Functional Specifications, in collaboration with vendors/developers and accordance to functional business needs.

    b) Reviewed deliverables and confirm system readiness for UAT (User Acceptance Test).

    c) Ensure UAT is conducted with a good quality.

    d) Ensure the initiatives are properly planned to meet business needs.

    d)

  • 06-03-2006 - 31-03-2010
    Executive, Accident

    1. Accountable on daily operation in processing life claims in order to meet or exceed productivity and service standard as defined by the management.


    2. Process all incoming request within the service standard and ensure all process are done prudently and in accordance to all regulatory and corporate requirements.


    3. Assisted in handling CASHless facility (Hospital Alliance Services) end-to-end from verifying all facts and eligibility prior to issuance of initial and final guarantee letter to all panel hospitals.

  • 01-03-2005 - 01-05-2006
    Contract Executive, Quantitative

    1. Worked alongside financial officer and rest of financial department to observe and learn investment practices.

    2. Conducted extensive research for reconciliation of all financial data regarding investment prospects.

    3. Carried out basis transaction in managing funds and developing understanding of nation and international corporate finance.

    4. Designed and implemented database for statistical information for forecasting related matters.

    5. Prepared weekly/monthly (as desired) financial statement detailing active and closing activities to be reviewed by management.