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Aetna is now a CVS Health Company

Coding Specialst/Health Service Manager

Primary Location: Blue Bell, PA
Additional Locations: PA-Blue Bell
The ideal candidate will evaluate professional and outpatient facility claims using specific criteria to determine if the claim is paid correctly. Candidate will focus on industry and company reimbursement and coding concepts to identify opportunities to pursue.

Fundamental Components:
  • Provide policy and coding guidance for initiatives driven by Medical Policy & Program Solutions (MPPS) and Analytics & Behavior Change (ABC)
  • Coordinate and conduct post-payment and root cause analysis to validate payment of professional and outpatient facility claims
  • Provide medical coding subject matter claim expertise to identify claim overpayments.
  • Identify potential waste and abuse by performing audits of claim data and electronic sources.
  • Communicate detailed description of the correct claim handling to internal and external constituents

Background Experience:
  • Professional coding certification is required
  • Must be familiar with CMS reimbursement policies, claim editing and industry coding concepts
  • Demonstrate basic knowledge of health insurance claim s processing.
  • Good investigation skills are a plus
  • Excellent verbal and written communication skills
  • Comfortable using various databases and computer systems to research and investigate opportunities

Required Skills:
General Business - Applying Reasoned Judgment, General Business - Communicating for Impact, General Business - Demonstrating Business and Industry Acumen

Desired Skills:
Finance - Managing Aetnas Risk, General Business - Consulting for Solutions, General Business - Maximizing Work Practices

Functional Skills:
Claim - Claims Administration - cost management, Claim - Policies & procedures, Clinical / Medical - FE Clinical coverage & policies, Medical Management - Medical Management - Coding, Project Management - Cost Management

Technology Experience:
Operating System - Windows

Information Technology - Certified Professional Coder (CPC)

Potential Telework Position:

Percent of Travel Required:
0 - 10%

EEO Statement:
Aetna is an Equal Opportunity, Affirmative Action Employer

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

Candidate Privacy Information:
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.

Click To Review Our Benefits (PDF)


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