Claims Monitoring
→
Operational Intelligence
From claims processing to operational monitoring, exception management,
data reporting and workflow enhancement.
Claims Monitoring Overview
From Claims Review to Operational Monitoring
After gaining experience in claims processing, I was assigned as a
Monitoring PIC to oversee claims that could not proceed directly
towards resolution or payment, while also monitoring team performance
and operational progress.
Claims Processing
→
Monitoring PIC
→
Exception & Performance Monitoring
→
Resolution / Payment
01 | Monitoring Role
Claims Monitoring PIC
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Managed claims that could not proceed due to documentation,
clinical, policy or operational issues.
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Monitored rejected claims, resubmissions and claims placed in
the alert pool to ensure timely resolution.
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Reviewed claim ageing and turnaround time (TAT), with follow-up
actions based on the duration of outstanding cases.
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Issued reminders to stakeholders for newer outstanding cases
and escalated cases exceeding 14 days through direct follow-up.
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Monitored claim movement and identified recurring issues requiring
clarification, amendment or further escalation.
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Monitored team-level claim activity and daily operational progress
to support workload allocation and performance tracking.
02 | Exception Monitoring & Resolution
Managing Claims Requiring Further Action
Rejected & Resubmission Claims
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Reviewed rejected claims, primarily involving documentation issues,
and followed up with relevant stakeholders for correction and
resubmission.
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Verified resubmitted claims to ensure the original issue had been
addressed and no repeated discrepancies remained before the claim
proceeded.
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Cleaned and organised rejected claim data to support follow-up,
tracking and operational reporting.
Alert Pool - Exception Cases
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Monitored claims placed in the alert pool where clinical, order
or outcome discrepancies required further clarification before
payment processing.
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Reviewed wrong-order cases where the hospital's
ordered procedure did not align with the clinical indication and
the procedure subsequently performed by the service provider.
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Returned discrepancies to the hospital for order amendment,
ensuring any resulting price changes were supported by the
hospital's revised order rather than introduced during claims
processing.
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Reviewed wrong-outcome declarations where a
procedure was declared as completed despite being abandoned due
to the patient's condition, and initiated follow-up for appropriate
amendment and justification.
03 | TAT Monitoring & Stakeholder Follow-up
Driving Outstanding Claims Towards Resolution
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Monitored the volume and ageing of claims that remained outstanding
for resolution or payment.
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Issued reminders to stakeholders for pending amendments,
clarifications and supporting documents.
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Prioritised follow-up based on claim ageing, with direct escalation
for cases exceeding the defined 14-day threshold.
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Monitored stakeholder responses and subsequent claim movement to
ensure outstanding cases progressed towards resolution.
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Used the monitoring output to support daily workload distribution
and prioritisation of claims requiring immediate attention.
04 | Data & Reporting Enhancement
From Manual KPI Preparation to Daily Operational Visibility
Daily monitoring initially relied on manual data extraction,
cleaning, validation and KPI preparation before being enhanced
into a structured and automated reporting workflow.
System CSV
→
Clean & Validate
→
Daily Reporting
→
Team Performance
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Initially downloaded nationwide claims data in CSV format and
manually cleaned and validated the data to identify inconsistent
or inaccurate records.
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Transformed the cleaned data using Excel and Pivot Tables to
generate daily claim volumes, trends, snapshots and workload
requirements for operational planning.
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Used daily reporting outputs to support task distribution and
workload allocation across the monitoring team.
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The original system-generated data primarily provided staff names,
claim counts and claim status, but did not directly link individual
claims to the staff handling them or capture the operational
remarks required for detailed performance monitoring.
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Identified the gap between the available system data and the
operational information required for monitoring, then structured
and transformed available data to improve visibility of claim
activity and ownership.
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Developed Power BI dashboards to visualise claim progress, backlog,
daily operational activity and team performance at the operational
claims level.
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Collaborated with IT and analytics teams to support structured
data integration and daily automated refresh capability.
05 | Data Processing & Automation
Reducing Repetitive Manual Data Handling
Excel & VBA Data Processing
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Used Excel Pivot Tables to summarise claims volumes, status, daily trends and operational snapshots for monitoring.
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Used Excel VBA to automate repetitive data filtering and
breakdown tasks for large datasets.
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Applied VBA to separate datasets based on operational criteria,
such as hospital, where standard Pivot Table functions were
not sufficient for the required output.
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Reduced repetitive manual handling when preparing datasets
for monitoring and stakeholder follow-up.
Power BI Operational Monitoring
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Developed Power BI dashboards to provide visibility of claim
volume, processing status, backlog and team performance.
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Structured the data model to support monitoring at the operational
claims level rather than relying solely on aggregate claim counts.
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Enabled daily D-1 data refresh so completed activities from the
previous working day could be visualised without waiting for
manual KPI preparation.
06 | Workflow Transformation
From Manual KPI Preparation to Data-Driven Monitoring
Manual CSV Extraction
→
Data Cleaning
→
Excel / Pivot
→
VBA Processing
→
Power BI
→
D-1 Visibility
The monitoring workflow evolved from manually prepared daily
reports into a structured data workflow with automated processing
and refresh, enabling more timely visibility of claim activity
and team performance.
07 | Impact
D-1
Latest Operational Performance
Power BI
Claims & Team Performance Visibility
VBA
Large Dataset Processing
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Enabled daily visibility of team performance based on the latest
completed D-1 activities.
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Reduced reliance on manually prepared KPI snapshots during
performance reviews.
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Improved visibility of claim-level activity beyond the basic
staff names, claim counts and status available from the original
system export.
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Reduced repetitive manual data cleaning, filtering and
hospital-level dataset preparation.
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Supported more timely identification of workload, backlog and
operational issues requiring stakeholder intervention.
Skills Developed
Claims Monitoring
Exception Management
Stakeholder Management
TAT Monitoring
Team Performance Monitoring
Root Cause Analysis
Data Cleaning
Excel
Excel VBA
Power BI
SQL
Operational Analytics
Process Improvement