Nisha Menon
Kuala Lumpur
Summary
Results-oriented Medical Advisor with 5+ years of healthcare experience specializing in medical management, patient care, and clinical adjudication. Skilled at analyzing complex health data to support evidence-based decisions and ensure accurate claims processing. Proven track record in identifying medical inconsistencies and supporting FWA investigations to maintain financial integrity and regulatory compliance. Strong communicator and negotiator adept at cross-functional collaboration with clinical, operations, and risk teams. Recognized for managing high-stakes medical cases and sensitive group accounts with precision and discretion. Committed to continuous learning and advancing healthcare outcomes through data-driven, ethical, and patient-centered approaches.
Overview
8
8
years of professional experience
Work History
Medical Advisor
Allianz Partners
12.2023 - Current
- Involvement in multiple projects across Asia Pacific region in particularly Singapore. Most notable projects include TPA IxChange cost containment with Google group clients flagging high cost providers.
- Auditing claims for leakage of costs due to internal errors and provided solutions with training assistance to staffs to reduce errors.
- Participated in monthly audit committee reviews, presenting risk assessments and resolution plans
- Global Medical Doctor - Involved in managing and auditing high cost ( >60K Euro) cases around the world while achieving cost containment and preventing leakage.
- Involved in designing policy benefits with an emphasis on operational feasibility, fraud detection triggers, and policy clarity to prevent billing and coverage ambiguities
- Acted as the subject matter expert for sensitive corporate group accounts, overseeing end-to-end claims handling with accountability for both operational workflows and medical necessity adjudication, particularly in cases flagged for potential fraud or abuse..
Senior Medical Advisor
Allianz Partners
01.2023 - 04.2023
- Assisted the healthcare provider in providing patient care by retrieving medical records, test results, medical supplies and other items.
- Uses data analysis skills to interpret medical records and other health-related information.
- Keeping track of multiple tasks and responsibilities within the team.
- Have the ability to interpret medical research to recommend treatment options for patients.
- Educating other colleagues from other department on health protocols, treatment plans and diagnosis.
- Specializing in medical adjudication for Asia Pacific medical claims.
Medical Advisor
Integrated Health Plans
08.2022 - 12.2022
- Uses data analysis skills to interpret medical records and other health-related information.
- Have the ability to interpret medical research to recommend treatment options for patients.
- Educating other colleagues from other department on health protocols, treatment plans and diagnosis.
- Keeping track of all the regulations and protocols in Ministry of Health.
- Adjudicating BUPA (British United Provident Association) related medical claims (clients seeking treatment in Malaysia).
- Excellent troubleshooting skills and problem solving claims involving complex medical procedure with their charges.
- Involved in IHP Chronic Care Program which caters to client's chronic care disease needs- pharmaceutical assistance as well as education on chronic diseases care.
Executive Network Provider Management
Prudential Assurance Malaysia Berhad
03.2021 - 08.2022
- Provided effective resolutions to issues and escalated problems with knowledgeable support and quality service.
- Consulted users to determine areas in need of improvement.
- Demonstrated self-reliance by meeting and exceeding workflow needs.
- Demonstrated leadership by making improvements to work processes and helping to train others.
- Juggled multiple projects and tasks to ensure high quality and timely delivery.
- Developed listing of medications with diagnosis under fraud analysis project.
- Analyzed hospitals costs and led negotiations with hospitals to come up with solutions to ensure cost effectiveness by developing dashboards which led to significant cost savings.
- Provided support on medical issues and resolved them accurately.
- Empanelled new hospitals and led negotiations to optimize these hospitals for our clients.
- Developed new SOPs for empanelling new hospitals ( under PAMB panel listing).
- Provided support on medical issues and resolved them accurately.
- Empaneled new hospitals and led negotiations to optimize these hospitals for our clients and developed new SOPs for empaneling new hospitals (under PAMB panel listing).
Medical Claims Assessor
Prudential Assurance Malaysia Berhad
02.2020 - 03.2021
- Reviewed company policies against best practices to better understand level of compliance.
- Investigated potentially fraudulent claims with focus on thoroughness, quality and cost control.
- Handled and processed variety of claims, including medical and HAS.
- Adhered to company and insurance client's guidelines in claims processes, estimate writing and claim closures.
Junior Doctor
Hospital Raja Permaisuri Bainun
07.2017 - 03.2019
- Provided patient diagnosis, test evaluation and treatment under strict time constraints.
- Recorded patients' medical history, vital statistics and test results in electronic medical records.
- Prescribed medications, explaining side effects and possible adverse reactions to keep patients informed and alert to potential issues.
- Monitored treatment regimens to determine efficacy and adjusted according to results achieved.
- Maintained strict patient privacy and confidential patient information, taking care to meet guidelines and statutes for data security.
- Assessed notes by nursing staff for accuracy, completion, services rendered and patient responses.
- Ordered laboratory tests and imaging scans to complete further investigations.
- Monitored patients with acute conditions for changes, improvements or need for intervention.
Education
Bachelor - Medicine, Surgery
Melaka Manipal Medical College
01.2016
Skills
- Medical Adjudication & Clinical Review
- FWA Investigation & Claims Integrity
- High-Profile Account Case Management
- Cost Containment Strategy & Negotiation
- Health Policy Interpretation & GOP Alignment
- Medical Coding (ICD/CPT) & Documentation Audit
- Claims Escalation Handling & Resolution
- Network Provider & Hospital Management
- SOP Development & Process Optimization
- Stakeholder Engagement & Internal Training
LANGUAGES
English: Fluent
Bahasa Melayu: Fluent
Tamil: Intermediate
Malayalam: Intermediate
Hobbies and Interests
SCUBA DIVING, READING,LISTENING TO METAL
Timeline
Medical Advisor
Allianz Partners
12.2023 - Current
Senior Medical Advisor
Allianz Partners
01.2023 - 04.2023
Medical Advisor
Integrated Health Plans
08.2022 - 12.2022
Executive Network Provider Management
Prudential Assurance Malaysia Berhad
03.2021 - 08.2022
Medical Claims Assessor
Prudential Assurance Malaysia Berhad
02.2020 - 03.2021
Junior Doctor
Hospital Raja Permaisuri Bainun
07.2017 - 03.2019
Bachelor - Medicine, Surgery
Melaka Manipal Medical College
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