Kerja Sepenuh Masa Assistant Manager, FWA and Health Sustainability, Gaji tinggi MYR 9,000 di Vipicks Resources Federal Territory - Maukerja

Job Purpose

• This role provides strategic medical and clinical oversight to strengthen claims governance through Fraud, Waste & Abuse (FWA) controls, with a key focus on leveraging Large Language Models (LLMs) and AI-driven solutions to enhance detection, audit efficiency, and decision consistency.
• The incumbent applies clinical judgment alongside AI-enabled insights to support investigations, audit reviews, complex case assessments, and escalation handling to ensure fair, defensible, and consistent claims outcomes.
• The role also contributes to advancing AI governance, prompt optimization, and model validation to improve medical claims integrity, reduce leakage, and enhance operational effectiveness.

Principal Duties & Responsibilities

A. FWA Investigation, Audit & Clinical Governance

1. Provide medical and clinical input for FWA investigations and audits, focusing on detection of inappropriate billing practices, unbundling, abuse patterns, and clinical inconsistencies.

2. Assess high-risk or complex cases for medical necessity, coding accuracy, and clinical validity, ensuring robust and defensible documentation of medical rationale.

3. Support escalations related to FWA, audit, and DRG matters, contributing to governance

strengthening and consistent claims decision-making.

B. AI / LLM Enablement for FWA

1. Support the development, implementation, and continuous improvement of LLM-powered

FWA solutions, including:

o Prompt design, refinement, and testing

o Validation of AI outputs against clinical accuracy and policy guidelines

o Identification of edge cases, biases, and false positives/negatives

2. Collaborate with data, analytics, and technology teams to:

o Enhance FWA detection logic and AI model performance

o Translate clinical requirements into AI/analytics rules and logic

o Ensure explainability, transparency, and auditability of AI decisions

3. Monitor and evaluate AI-driven audit outcomes to ensure alignment with:

o Medical best practices

o Regulatory requirements

o Internal governance standards

C. Cost Containment & Claims Integrity

1. Provide clinical insights to identify cost drivers, recommend appropriate controls, and support value-based claims assessment.

2. Contribute to initiatives aimed at reducing claims leakage while maintaining fair and

sustainable outcomes.

D. Complex Case Management & Stakeholder Engagement

1. Coordinate complex referrals requiring external expert opinions, ensuring compliance with regulatory and internal governance standards.

2. Support stakeholders in managing complex or sensitive cases, including customer escalations and provider discussions.

3. Engage with healthcare providers and regulators (e.g., Ministry of Health) where required to ensure alignment on claim eligibility and accuracy.

E. Panel Governance & Compliance

1. Manage Doctor Panel governance, including monitoring, audit reviews, and oversight of

watch-listed or delisted providers.

2. Ensure adherence to local regulatory requirements and internal policies in all claims-related decisions and activities.

F. Training, Process Improvement & Projects

1. Design and deliver structured training, case studies, and guidance for claims assessors to

strengthen FWA controls and improve consistency.

2. Support continuous improvement initiatives across processes, systems, and AI tools to

enhance efficiency, quality, and cost management.

3. Participate in strategic projects, including new product development, regulatory initiatives, and AI-driven transformation programs.

G. Professional Development

1. Maintain up-to-date clinical, industry, and AI/analytics knowledge to support evolving claims and FWA practices.

2. Uphold high standards of professionalism, customer service, and ethical conduct.

Job Specifications

a. Qualifications

 Degree in Medical, Nursing, or Allied Health Sciences

 Additional qualifications in business, insurance, analytics, or AI/technology will be an advantage

b. Experience

 Minimum 8–10 years of experience in insurance, healthcare, or medical claims

 Strong experience in:

o Medical claims assessment and clinical evaluation

o FWA investigation or audit

o Stakeholder engagement (providers, regulators, customers)

 Exposure to AI/analytics, FWA systems, or digital transformation initiatives is highly

preferred

 Experience in training or coaching claims teams is an added advantage

c. Knowledge & Skills

 Strong knowledge of:

o Medical insurance claims and clinical practices

o FWA detection and audit methodologies

o DRG and coding principles

 Preferred capabilities:

o Understanding of LLM/AI applications in claims or FWA

o Experience in prompt engineering, AI validation, or audit logic development

o Analytical thinking and ability to translate clinical insights into system logic

 Core competencies:

o Critical thinking and clinical judgment

o Strong communication and stakeholder management

o High attention to detail and governance mindset

Pay: RM6,000.00 - RM9,000.00 per month

Education:

• Bachelor's (Preferred)

Experience:

• insurance/healthcare/medical claims: 8 years (Required)
• FWA system: 8 years (Preferred)
• AI analystics: 8 years (Preferred)
• AI validation: 8 years (Preferred)

Work Location: In person