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Claim Manager

Primary Location: Shanghai, China
Additional Locations: CHN-Shanghai

The global operations team isresponsible for delivering world-class service to our members, internalcustomers and providers.We are the faceof Aetna and provide 24x7 global support, front line customer services, claimsand product expertise.

We believe that a positive memberexperience starts with investment in our people. Our aim is to communicate withour customers on their terms, through local teams, in local languages.We want to know our customers, own ourrelationships with them, predict their needs and meet them proactively.We ensure our members get the healthcare theyneed, when they need it, with maximum value and minimum effort.


·Member and provider claim adjudication

·Claim administration, including the handling ofmember and provider claim documentation, and liaison with China frontingcompanies for claim reimbursement.

·Network operations, including the management ofthe Direct billing network provider reconciliation and the public hospitalrepresentative team

·Claim data analytics and reporting, claim systemissue resolution and UAT support

Fundamental Components & Physical Requirements

·Hires, mentors, coaches, develops, trains,evaluates, compensates and monitors/disciplines staff to provide effectiveclaim management services while ensuring quality standards are met.

·Ensures that performance evaluations andcompensation decisions for employees are not influenced by the financialoutcomes of claims decisions.

(*) Hasresponsibility for claim results by promoting competent claim and riskmanagement.

(*) Hasresponsibility for claim financial results by promoting competent claim andrisk management of multi-million-dollar book of business.

·Challenges and motivates staff to be responsiveto performance expectations in a rapidly changing work environment. Assessesbusiness requirements and assigns team resources to support new business

·implementations; collaborates withimplementation manager, plan sponsors, consultants and sales to ensure strongcustomer satisfaction and meet product objectives. Serves as an agent to drivechange across the organization; communicates workflow results, ideas andsolutions.

·Initiates, develops and manages qualityimprovement and claim management programs.

·Implements appropriate revisions to businessperformance measures.

·Incorporates unit results into performanceevaluations and reward systems.

·Develops and participates in presentations tointernal and external customers.

·Identifies trends and root cause issues anddrives resources to achieve a resolution.

·Assesses individual and team performance on aregular basis and provides candid and timely developmental feedback. Developstraining plans and ensure training needs are met.

·Establishes a clear vision aligned with companyvalues. Motivates others to balance customer needs and business success.

·Attracts, selects, and retains high caliber,diverse talent able to successfully achieve or exceed business goals. Builds acohesive team that works well together.

·Leverages the unit’s resources to resolve plan,claim and call inquiries or problems by identifying the issue, obtainingapplicable information, performing root cause analysis, and generating andacting upon the solutions.

·Manages and monitors daily workflow andreporting to ensure business objectives are maintained and accurately reported;ensures resources are aligned appropriately across function and/or servicecenter. Effectively applies and enforces Aetna HR policies and practices, i.e.,FML/EML, Attendance, Code of Conduct, Disciplinary Guidelines.

·Ensures regulatory compliance with policies andprocedures.

·Enforces authority limit policy and procedure.

·Uses critical thinking and extensive knowledgeof Aetna systems and processes to evaluate impact of customer requestedexceptions and develops reasonable alternatives to satisfy clients’ needs whileminimizing impact on Aetna systems and operations.

·Actively contributes to the decision-makingprocess that impacts profitability and retention of business when collaboratingon review, analysis and development of recommendations for the design of complexaccount and benefit structures based on customers’ objectives and Aetnasystems.

·Coordinates resources to ensure a successfulcase installation of new products and services.

·Maximizes sales by articulating how Aetna’scapabilities can contribute to constituents’ long-term strategies.

·Delivers organized polished presentation ofsolutions with benefits tied to constituent needs.

·Identifies and analyzes the impact from bothupstream and downstream contributors to problems, and then partners extensivelyacross business functions to proactively resolve developing service deliveryissues.

Background/experience desired:

·University level of education or higher.Equivalent qualification and/or experiencemay be considered.

·Experience in an insurance and/or healthcareenvironment is essential.

·Demonstrable success in a claim team managementrole for minimum of 3 years prior.

·Fluent written and spoken English with secondlanguage being desirable.

Additional information:

·You’ll need to demonstrate the following:

·A passion for providing outstanding customerexperience.Excellent listening skills.

·An ability to solve complex challenges.Self-motivation with an ability to work onyour own initiative

·Effective collaboration and team working.A high degree of accuracy and a keen eye fordetail

·High levels of organizational skills with theability to prioritize and multi-task.

·The desire to make things better.And the ability to ask questions or seekclarification if you need help or are unclear.

·Eager to work in a high energy, fast-pacedbusiness, where change is a constant

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

Click To Review Our Benefits (PDF)


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