Aetna Quality Analyst - Claim Audit in Tampa, Florida

Req ID: 50571BR

POSITION SUMMARY

Primary responsibility of this position is to review all types of medical and dental claims for accuracy, using the groups plan documents, Meritain Health procedures and industry standards. Our objective is reporting for company, group and individual accuracy statistics, training feedback and trending of issues both for system and examiner adjudication.

Fundamental Components:

  • Audit medical and/or dental claims. (30%) - Analyze and interpret plan documents. (30%) - Troubleshoot and propose solutions to decrease audit errors. (20%) - Provide investigative support to management(5%) - Document new procedures, as needed. (5%) - Request claim adjustments when needed (5%) - Cross train on other responsibilities within the department (5%)

    BACKGROUND/EXPERIENCE desired:

  • 1-3 years of claim processing and/or claims auditing experience.

  • Knowledge of heath claim processing (example: COB, Medical necessity, pre-existing, U&C)

  • Keyboard and computer familiarity.

  • Knowledge of Preferred Provider Organizations.

    EDUCATION

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

    FUNCTIONAL EXPERIENCES

    Functional - Claims/Claim processing - Dental/1-3 Years

    Functional - Claims/Claim processing - Medical or Hospital - ACAS/1-3 Years

    Functional - Claims/Quality management/1-3 Years

    Functional - Customer Service/Customer service - Medical billing/1-3 Years

    TECHNOLOGY EXPERIENCES

    Technical - Computer Operations/System and Console Operations/1-3 Years/End User

    Technical - Aetna Applications//1-3 Years/End User

    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: Quality Management