Medical Claims Analyst

About the role

We are seeking a Medical Claims Analyst to join Zurich Insurance Company Ltd. in Kuala Lumpur. The role involves analysing medical claims, ensuring regulatory compliance, and supporting operational excellence within our claims department.

Key responsibilities

• Conduct medical claims analysis and deep‑dive reviews to ensure compliance with regulations, coding rules and internal guidelines.
• Analyse claims data and processes to identify leakage, compliance issues, operational risks and improvement opportunities.
• Identify and report suspected fraud or suspicious billing, escalating to senior team members when necessary.
• Perform audits and reviews of claims files, processes and documentation to check accuracy, quality and adherence to standards.
• Prepare clear audit reports that enable managers to understand issues and implement remediation.
• Lead and coordinate regulatory, management and TPA reporting for medical claims, ensuring data quality and timely submissions.
• Support day‑to‑day medical claims operations, including TPA management, reporting and administrative tasks.
• Monitor and report on TPA performance against service level agreements, covering quality, cost and customer outcomes.
• Provide data analysis and business insights using reports, KPIs, scorecards and forecasts to support internal teams and customers.
• Contribute to process improvement initiatives and system enhancements to increase efficiency and control effectiveness.
• Investigate and resolve operational issues related to medical bill review, including data validation and system problems.
• Support quality audits, coaching and technical guidance to maintain high standards of service and compliance.