Aetna Network Audit Quality Analyst in St Louis, Missouri

Req ID: 49748BR

POSITION SUMMARY

Performs routine quality audits for network operations, and claim testing for PPO Network creation.

Fundamental Components:

Conduct standard quality reviews /audits to measure compliance with published policies, procedures, customer and regulatory guidelines (*)

Identify and distribute errors to business partners (*)

Assist with the day-to-day maintenance and operations of assigned functional unit (*)

Perform analysis of data to identify and communicate trends during day to day work (*)

May perform or assist with special projects/reviews

May provide technical or subject matter expertise concerning policies, procedures, and function-related applications/systems tools

Subject matter expert on workflows, policies, components of systems and on daily operations and programs

Responsible to support targeted quality audit projects. Report results and make recommendations e.g., training needs, quality controls and procedures)

In partnership with business owners, support the design and development of new processes

Develop and implement quality programs and initiatives. Participate in the development and validation of master or detail test plans and strategies

Analyze and resolve complex claims scenarios within established time frames

Resolves problems in a timely and effective manner.

Uses designated systems to obtain information. Understands the impact of actions on system primarily used/maintained. Understands relationships of designated systems.

Analyzes and verifies system results to ensure accuracy, accountability and financial data integrity.

Possesses working knowledge of functions of other units in department Responds to and resolves customer inquiries and complaints (internal as well as external) both verbal and written correspondence within established unit objectives.

Analyzes and resolves system error conditions within established unit time frames.

Analyzes and recommends solutions to non-standard requests and requirements from plan sponsors and areas within and outside the area.

Monitors, reviews, researches, reconciles and balances designated Aetna system activity.

BACKGROUND/EXPERIENCE desired:

2+ years claim processing experience.

Experience in a production environment.

Claim processing experience.

Claim testing experience.

Working knowledge of PPO Networks.

Demonstrated ability to handle multiple assignments competently, accurately and efficiently.

EDUCATION

The highest level of education desired for candidates in this position is a Bachelor's degree or equivalent experience.

FUNCTIONAL EXPERIENCES

Functional - Claims/Quality management/1-3 Years

REQUIRED SKILLS

General Business/Communicating for Impact/FOUNDATION

Service/Working Across Boundaries/FOUNDATION

Service/Providing Solutions to Constituent Needs/ADVANCED

ADDITIONAL JOB INFORMATION

Aetna is about more than just doing a job. This is our opportunity to re-shape healthcare for America and across the globe. We are developing solutions to improve the quality and affordability of healthcare. What we do will benefit generations to come.

We care about each other, our customers and our communities. We are inspired to make a difference, and we are committed to integrity and excellence.

Together we will empower people to live healthier lives.

Aetna is an equal opportunity & affirmative action employer. All qualified applicants will receive consideration for employment regardless of personal characteristics or status. We take affirmative action to recruit, select and develop women, people of color, veterans and individuals with disabilities.

We are a company built on excellence. We have a culture that values growth, achievement and diversity and a workplace where your voice can be heard.

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

Aetna takes our candidate's data privacy seriously. At no time will any Aetna recruiter or employee request any financial or personal information (Social Security Number, Credit card information for direct deposit, etc.) from you via e-mail. Any requests for information will be discussed prior and will be conducted through a secure website provided by the recruiter. Should you be asked for such information, please notify us immediately.

Job Function: Claim