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.
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