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Aetna Claim Benefit Specialist in Shanghai, China

Req ID: 64375BR

Job Description

Family Summary/Mission:

Achieve superior claim and member service performance through an integrated process of operational, quality, medical cost, and resource management meeting and/or exceeding member, plan sponsor, and provider expectations.

Position Summary/Mission:

Reviews and adjudicates claims in accordance with claim processing guidelines

Fundamental Components & Physical Requirements:

Analyzes and approves Claims

Applies medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and applies all cost containment measures to assist in the claim adjudication process

Coordinates responses for phone inquiries and written correspondence related to claim processing issues

Routes and triages High $ claims and seeks support and advice from designated Specialists. (Senior Claim Benefits Specialist)

Proofs claim or referral submission to determine, review, or apply appropriate guidelines, coding, member identification processes, provider selection processes, claim coding, including procedure, diagnosis and pre-coding requirements

Investigate claims for possible abuse and fraud

May facilitate training when considered topic subject matter expert

In accordance with prescribed operational guidelines, manages claims on desk, route/queues, and all systems within specified turn-around-time parameters

Utilizes all applicable system functions available ensuring accurate and timely claim processing service (i.e., use of all documented resources)

Escalate unresolved claims complaints and high costs claims to the claims supervisor for guidance

Continually work to improve best practices procedures and standards

Ensures compliance with requirements of regional compliance authority/industry regulator

Adheres to international privacy policies, practices and procedures

Exhibits behaviors outlined in Claim Benefit Specialist Competencies

Background/Experience Desired:

Experience in a production environment..

Claim processing experience

Data Entry Experience

Educational Requirements:

High School graduate or local market equivalent

Additional Information (not mandatory to complete):

Ability to maintain accuracy and production standards

Analytical skills

Technical skills

Excellent oral and written communication skills

Understanding of medical terminology

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.

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