Functional Lead (Insurance Claims)

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.