Key Responsibilities
* Serve as the company's functional lead for claims during all phases of the implementation.
* Act as the functional anchor for all claims-related requirements, workshops, and design validations-working directly with the customer and representing the company's product with domain authority.
* Conduct and lead requirement workshops, including discovery, process validation, and data mapping sessions.
* Lead workshops with confidence, validate use cases, map requirements, and guide the customer through best practices-avoiding vague elicitation.
* Understand Hong Kong's health claims landscape-including:
- VHIS products and top-up riders
- Pre-authorisation flows and provider billing logic
- Medical coding standards (ICD, PCS, TOSP)
- Provider networks and reimbursement models
- Claims SLAs, appeals, regulatory workflows, and audit readiness
* Provide clear, assertive guidance to customers-mapping their needs to the company's product capabilities and identifying any configuration/localisation required.
* Act as a bridge between the customer's business team and the company's offshore implementation and product teams (India-based).
* Support test scenario definition, UAT planning, and go-live validation, ensuring alignment to the functional use cases.
* Review product enhancements or localisation requests to ensure they are truly needed and not a workaround for missing understanding.
* Document all validated requirements in collaboration with Business Analysts and maintain traceability.
Required Skills & Experience
* 10+ years of experience in the health insurance claims domain.
* Deep understanding of end-to-end health insurance claims processing in Hong Kong, including:
- Pre-authorisation
- Provider management
- ICD/PCS codes
- Adjudication rules
- Regulatory expectations
* Strong domain knowledge across claims processing, provider management, benefit adjudication, and regulatory compliance.
* Prior experience working on claims platform implementations or transformation projects in Hong Kong or other APAC health insurance markets.
* Familiarity with:
- ICD, PCS, and surgical procedure codes
- Medical necessity and coding validation
- Claim-to-policy benefit mapping
- Eligibility verification and co-pay/deductible logic
* Ability to lead workshops, navigate ambiguity, and guide business users confidently.
* Excellent communication skills in English; Cantonese proficiency is preferred but not mandatory.
* Ability to interact closely with Hong Kong-based business users and health claims teams.
* Ability to work with offshore teams and represent the product roadmap, configurability, and functional boundaries clearly.
Preferred Qualifications
* Experience working with Hong Kong-based life and health insurers.
* Functional experience with auto-adjudication engines, pre-auth platforms, or provider portals.
* Exposure to regulatory guidelines from FHB, IA, or MOH in Hong Kong.
* Clinical coding background or familiarity with coding audit processes is a strong plus.
* Bachelor's degree in Life Sciences, Insurance, Healthcare Administration, or equivalent.
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