Medical Director in Penang or KL

We provide managed healthcare services to corporate clients ranging from SMEs to MNCs.

Responsibilities

• Medical/Regulatory Oversight
  • Serve as Clinical Governance Officer (CGO) for all our clinics
  • Lead audit preparation and execution to ensure regulatory compliance
  • Act as the ordering doctor for laboratory and imaging tests, including prompt responses to critical results
  • Address general medical regulations queries from internal and external stakeholders
  • Lead initiatives to manage and reduce the cost of medical claims through clinical review, provider negotiation, and strategic interventions.
  • Conduct and oversee claims audits, identifying patterns of overutilization or fraud, waste, and abuse (FWA).
  • Monitor provider performance and billing behavior to identify and mitigate fraud, waste, and abuse (FWA); initiate corrective actions where necessary.
  • Develop internal cost containment SOPs and workflows in collaboration with operational teams to streamline claims processing and medical adjudication.
  • Act as the primary client-facing representative for all matters related to medical cost containment.
  • Prepare regular reports and presentations for leadership and clients, highlighting key cost drivers, trends, and opportunities for optimization.
• Clinical Support
  • Review Patient Information Leaflets (PIL)
  • Perform regular medication reviews and sign off for VIP, ensuring safe and effective treatment plans
• Claims, LOG and Pre-Authorization
  • Act as the final medical escalation point for claims, LOG, and pre-authorization within the company
  • Develop and refine general guidelines and definitions for medical reimbursable claims
  • Provide strategic support to the Claims and LOG teams in developing and enhancing STP workflows and overall process improvements
• Business Development Support
  • Participate in presentations and stakeholder engagement as a clinical representative
  • Collaborate on workflow reviews to align clinical operations with BD initiatives
  • Contribute to the ongoing refinement of company data analytics, offering client insights and actionable strategies.
  • Provide KIV support for on-site rollout of services
  • Participation in initiative-based projects as required, including clinical input and representation in BD-related presentations and discussions
• Chronic disease management program- Involvement in design, execution, and evaluation
• LPA program- Support for program rollout and medical compliance

Job Requirements

• Medical Degree from a recognized university (MD or MBBS preferred)
• Minimum 5 years of relevant experience in TPA or insurance company
• Willingness to support after-office-hours remotely