Aetna Sr Claims Benefit Spec in Shanghai, China

Req ID: 51992BR


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

Position Summary

Reviews and adjudicates complex, sensitive, and/orspecialized claims in accordance with claim processing guidelines. Acts as asubject matter expert by providing training, coaching, or responding to complexissues. May handle customer service inquiries and problems


· Reviewspre-specified claims or claims that exceed specialist adjudication authority orprocessing expertise

· Assistto establish the business planning & strategy for claim department

· Qualitycheck for the accuracy of claim data including claim entry, procedure code andrelated workflows.

· Deliveringclaim training sessions to develop, maintain and enhance the performance skillsand proficiencies of claim team.

· Applies medicalnecessity guidelines, determine coverage, complete eligibility verification,identify discrepancies, and apply all cost containment measures to assist inthe claim adjudication process

· Distributeswork assignments daily to staff

· Mentorsjunior claims staff

· Handles phoneand written inquiries related to requests for pre-approvals/pre-authorizations,reconsiderations, or appeals

· Identifies andreports possible claim overpayments, underpayments and any otherirregularities.

· Ensurescompliance with requirements of regional compliance authority/industryregulator

· Ensures allcompliance requirements are satisfied and that all payments are made againstcompany practices and procedures

· Proactivelyanalyzes claim data, identifies trends and issues.

· Identifiesmost urgent claim problems, obtains necessary information, accuratelyidentifies root causes and generates solutions.

· Analyzeand approve the large claims

· Investigateclaims for possible abuse and fraud.

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

· Ensurescompliance with requirements of regional compliance authority/industryregulator.

· Demonstratedability to handle multiple assignments competently, accurately and efficiently.

· Adheresto international privacy policies, practices and procedures.

· Compiles ClaimsData for Customer Service Audits


· 5years plus claim experience, health care/insurance industry experience ispreferred.

· Strongcommunication skills (verbal, written in Chinese & English).

· Abilityto work with cross-functional business units and vendors.

· Criticalthinking and decision making skills.

· Bachelordegree and/or relevant experience

· Advanceskills in Microsoft office applications.

Job Function: Claim