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Medical Claim Analyst

Primary Location: Phoenix, AZ
Additional Locations: AZ-Phoenix
To promptly review, analyze and provide accurate claim information in order to optimize savings on appropriate claims, while ensuring that customer satisfaction needs are not compromised. Provide clear benefit responses to the customer in an expedient manner.

Fundamental Components:
  • Develop policy and procedure for medical claim cost management Analyze provider billing practices.
  • Identify trends and cost saving opportunities; work with Medical/Provider Services to address provider education
  • Develop and deliver training programs with regard to CPT billing appropriateness and Health Plan guidelines for claim processors
  • Reviews pre-specified claims for CPT coding appropriateness and may adjudicate the claim Identify improvement opportunities and recommend workable solutions supported by cost benefit analysis
  • Handles telephone and written inquiries from providers.
  • Responds to all requests for reconsiderations or appeals
  • Works directly with vendor to quickly review high priority claims.
  • Evaluates and tests automated code review programs
  • May recommend provider contract language to support medical cost management
  • Apply the appropriate contractual and plan benefits to claims reviewed for $20K, pre-audit, stop loss, NAP reviews and ad-hoc negotiations
  • Determines coverage, verifies eligibility, order of benefits, identifies discrepancies and applies all Medical Claim Management policies and procedures to assist in ensuring correct claim adjudication
  • Works with all appropriate internal and external departments and personnel to accurately review specified claims and/or clarify medical necessity and billing appropriateness
  • Assists with the development and implementation of Medical Claim Management awareness programs when required
  • Accurate and timely reporting of savings results on MCRT
  • Updates reporting vehicle with required information and data on a timely basis as indicated by management
  • Maintains and utilizes all resource materials and systems to effectively manage job responsibilities

Background Experience:
  • 2+ years claim processing experience and demonstrated ability to handle multiple assignments competently, accurately and efficiently.
  • High School Diploma or G.E.D.

Additional Job Information:
  • Effective communication skills, both verbal and written.Understanding of medical necessity guidelines and managed care concepts.
  • Extensive knowledge of CPT, ICD9, medical terminology, and provider billing practices.

Required Skills:
General Business - Demonstrating Business and Industry Acumen

Desired Skills:
Service - Working Across Boundaries

Functional Skills:
Clinical / Medical - Clinical claim review & coding

Technology Experience:
Desktop Tool - Microsoft Explorer, Desktop Tool - Microsoft Outlook, Desktop Tool - TE Microsoft Excel

Potential Telework Position:

Percent of Travel Required:
10 - 25%

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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