Company Description Sembuh AI is a trusted partner for the global health insurance ecosystem, powering modern insurers, TPAs, reinsurers, and brokers with smarter claims intelligence. Our technology uses Artificial Intelligence that integrates with existing systems to automate claims processing, enhance fraud detection, and improve portfolio visibility. We empower insurance providers with smarter, faster, and fairer claims handling, driving real impact across the insurance industry.
Responsibilities
- Receive, log, and categorise all incoming claims (inpatient cashless, reimbursement, outpatient) into the Sembuh AI system; ensure correct initial data entry
- Verify administrative compliance against policy terms (benefit limits, waiting periods, exclusions, coverage scope); review AI-flagged claims for non-clinical discrepancies without making clinical determinations
- Verify AI-generated inconsistencies, fraud indicators, and red flags in claims data alongside AI-generated risk scores; escalate clinically complex or suspicious cases to the Medical Doctor before finalizing
- Coordinate with external parties to obtain, verify, and chase outstanding documents; maintain a clear follow-up log
- Communicate decisions and findings to internal stakeholders clearly; provide domain feedback to the product and tech team to improve AI model accuracy and escalation logic
Qualifications
- Preferably someone with minimum two years of hands-on experience in insurance claims handling or adjudication
- Strong working knowledge of health or employment benefit insurance claims processes, medical billing, and policy interpretation
- Experience identifying and investigating fraudulent or suspicious claims
- Comfortable working with AI-assisted tools and digital claims systems — tech-savvy approach to the work
- Detail-oriented with strong analytical and documentation skills
- Excellent communication skills, able to explain complex decisions to both technical teams and business stakeholders
Must Have
- Bachelor's degree from any major
- Ability to multitask, manage multiple cases simultaneously, and meet time-sensitive deadlines with integrity and professionalism
- Comfortable working with AI-assisted tools and digital claims systems, tech-savvy approach to the work
- Proficiency in English and Bahasa Indonesia, both written and spoken
Strong Advantage
- familiarity with ICD-10/11 coding and cashless/reimbursement claim workflows
- Fluent in professional English both spoken and written
- Actively using AI tools, especially Claude, in daily workflows is a plus point
- Experience or flexibility working in lean teams where ownership is high and role boundaries are not rigid
Working Arrangement
- Jakarta-based or near Jakarta area, Onsite and willing to commute
- This role is expected to operate closely with leadership and cross-functional teams, so strong in-person collaboration is important
