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Aetna Medical Claim Analyst in Phoenix, Arizona

Req ID: 66367BR

Job Description

To promptly review, analyze and provide accurate claim information in order to optimize savings on appropriate claims, while ensuring that customer satisfaction needs are not compromised. Provide clear benefit responses to the customer in an expedient manner.

Fundamental Components included but are not limited to:

  • Develop policy and procedure for medical claim cost management Analyze provider billing practices.

  • Identify trends and cost saving opportunities; work with Medical/Provider Services to address provider education

  • Develop and deliver training programs with regard to CPT billing appropriateness and Health Plan guidelines for claim processors

  • Reviews pre-specified claims for CPT coding appropriateness and may adjudicate the claim Identify improvement opportunities and recommend workable solutions supported by cost benefit analysis

  • Handles telephone and written inquiries from providers.

  • Responds to all requests for reconsiderations or appeals

  • Works directly with vendor to quickly review high priority claims.

  • Evaluates and tests automated code review programs

  • May recommend provider contract language to support medical cost management

  • Apply the appropriate contractual and plan benefits to claims reviewed for $20K, pre-audit, stop loss, NAP reviews and ad-hoc negotiations

  • Determines coverage, verifies eligibility, order of benefits, identifies discrepancies and applies all Medical Claim Management policies and procedures to assist in ensuring correct claim adjudication

  • Works with all appropriate internal and external departments and personnel to accurately review specified claims and/or clarify medical necessity and billing appropriateness

  • Assists with the development and implementation of Medical Claim Management awareness programs when required

  • Accurate and timely reporting of savings results on MCRT

  • Updates reporting vehicle with required information and data on a timely basis as indicated by management

  • Maintains and utilizes all resource materials and systems to effectively manage job responsibilities

Qualifications Requirements and Preferences:

  • 2+ years claim processing experience and demonstrated ability to handle multiple assignments competently, accurately and efficiently.

  • High School Diploma or G.E.D.

Functional Skills:

Clinical / Medical - Clinical claim review & coding

Technology Experience:

Desktop Tool - Microsoft Explorer, Desktop Tool - Microsoft Outlook, Desktop Tool - TE Microsoft Excel

Required Skills:

General Business - Demonstrating Business and Industry Acumen

Desired Skills:

Service - Working Across Boundaries

Additional Job Information:

  • Effective communication skills, both verbal and written.Understanding of medical necessity guidelines and managed care concepts.

  • Extensive knowledge of CPT, ICD9, medical terminology, and provider billing practices.

Benefit Eligibility

Benefit eligibility may vary by position. Click here to review the benefits associated with this position.

Job Function: Claim

Aetna is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected Veterans status.