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A new day in healthcare. Together, CVS Health and Aetna help people on their path to better health.

Quality Analyst Lead- ACAS

Primary Location: Scottsdale, Arizona
Additional Locations: AZ-Scottsdale, CA-Fresno, CT-Hartford, FL-Jacksonville, NC-High Point, ND-Bismarck, NY-Albany, OH-New Albany, PA-Allentown, PA-Blue Bell, PA-Harrisburg, PA-Moon township, TX-Arlington, TX-San Antonio, UT-Sandy
The Enterprise Quality assurance program and fiduciary control for Aetna. Performs quality audits for service operations for multiple products and platforms and is the official source for Customer/Plan Sponsor performance guarantee reporting, SOX and SOC1, Internal Audit/Compliance controls and the official source for Service Level Agreements ( SLA for Vendor) and Book of Business reporting. Candidates who enjoy a challenge and who are looking to grow within a fast-paced environment will be successful in this position.

Lead quality reviews /audits with a higher level of complexity across multiple platforms and/or products to measure compliance with published policies, procedures, customer and regulatory guidelines. Audit programs may include: Claim Prepayment, Stratified and End to End for SOX and Sarbanes controls, performance guarantee, book of business and Service Level Agreement reporting. Provide guidance, mentor and/or developing others on audit programs. Perform root cause analysis and/or analyze data to identify, communicate trends and deliver results in day-to- day work (e.g., quality of results, efficiencies of processes, etc.). Subject matter expert on workflows, policies, systems requirements/enhancements.

2-5+ years experience in an audit environment and/or complex claim processing and extensive platform experience that reflects a proven track record or proficiency with hospital (inpatient/outpatient), physician, and rework claims. In depth knowledge & understanding of ACAS is required. Experience with handling high dollar claims of $10K or more required. Must have achieved a successful or higher rating on last balanced scorecard review.

The highest level of education desired for candidates in this position is a High School diploma, G.E.D. or equivalent experience.

Functional - Claims/Claim processing - Medical or Hospital - ACAS/1-3 Years
Functional - Claims/Claim processing - Medical - Transplant/1-3 Years
Functional - Claims/Policies & procedures/1-3 Years

Telework Specifications:
Considered only for current internal teleworkers (in any area) or Service Ops Strategic Office Locations

Claim Quality is an exciting and fast paced high performance organization. We are Aetna's Enterprise Level Quality Assurance Program. The Claim Quality team promotes quality improvement, trending and training opportunities. Claim Quality is the official source for all customer performance guarantee and key performance metric reporting and is the SOX and Sarbanes control for ACAS Claim Processing.

We are looking for a flexible customer focused individual who enjoys working in a team environment and can create value by anticipating and exceeding customer expectations. The ideal candidate will have exceptional analytical, organizational and problem solving skills effective verbal and written communication skills, the ability to adapt quickly and willingly to change, and a positive attitude. Prior medical and hospital claim processing experience is required. Successful candidates should be comfortable with quality and production goals.

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 candidates'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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