Key Responsibilities & Accountabilities

• Develop and maintain a comprehensive understanding of insurance operational guidelines, standard operating procedures (SOPs), policy terms, and legal frameworks.

• Acquire technical proficiency to effectively manage system-related issues, including bug reporting and outage resolution.

• Rigorously validate medical request documentation submitted via ticketing or online systems.

• Adhering to established operational guidelines and SOPs.

• Accurately input request data into the system, ensuring thorough database maintenance and documentation prior to decision-making.

• Thoroughly assess medical requests, gathering all necessary information to support informed decision-making.

• Suspend requests requiring further investigation and resolve them within quality standards.

• Proactively identify fraudulent request patterns, flag suspicious cases for investigation, and report wasteful practices to relevant departments.

• Respond to inquiries and requests from internal departments, including Customer Service, Client Relations, Claims, Fraud Waste & Abuse, Sales, and Complaints, within authorized boundaries and department guidelines.

• Collaborate with other departments to resolve complex requests and propose solutions to prevent recurrence.

• Maintain flexibility to work shifts as determined by supervisors and managers to align with capacity planning and operational needs.

• Maintain full compliance of department to AXA standards and reactivity/contribution to all compliance processes.

Job Specifications

Education / Certification

• Bachelor of pharmaceutical sciences

• 0-3 Year of Experience

Soft Skills & Behavioral Competencies

• Pharmaceutical Practice / Medical Practice.

• Strong interpersonal and customer service orientation.

• Proficiency in computer applications.

• Ability to multitask and prioritize tasks effectively.

• Strong problem-solving and decision-making skills.

• Attention to detail and accuracy.

• Knowledge of insurance products and processes (preferred)

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