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Claims Associate

Primary Location: Shanghai, CHN
Additional Locations: CHN-Shanghai
Fundamental Components & Physical Requirements include but are not limited to (* denotes essential functions)
• Triage and logging of incoming claims.
• Scanning claims to work-queues for processing across all operational platforms.
• Provider claims batch control linked between the platform (Actisure IG, Actisure Aetna, and OpenHealth Plus).
• Management of provider payments - create/run a provider bordereau, check that all invoices match the provider
submission summary, identify and re-open for corrections where required, release the batch to finance for payment
and once paid liaise with network team to inform the provider of the payment and claim details.
• Claims vendor queries - reviewing claims on the various platforms, investigating processing queries and responding
as appropriate to ensure that the claims batch flows.
• Provider claims batch control linked between the platform (Actisure IG, Actisure Aetna, and OpenHealth Plus).
• Management of suspended claims including outreach by calls and emails where appropriate.
• Finance queries - including managing OFAC issues - investigating, resolving issues and liaising with finance and
customer to resolution.
• Payment report management - investigating processed payments pending (not paid) and identifying a solution to
release the payment.
• E-claims reconciliation - Utilizing the recon tool to investigate, identify, correct and manually remit where e-claim
remittance has failed.
• Manual claims reconciliation - reviewing re-subs on the various platforms to identify current status, outstanding issues,
correcting, and liaising with the claims vendor for processing
• Continually work to improve best practices procedures and standards.
• Ensures compliance with requirements of regional compliance authority/industry regulator.
• Adheres to international privacy policies, practices and procedures.
• Exhibits the following Employee Behaviors
Background/Experience Desired
• 2 years’ experience in a production environment.
• Claim processing experience.
• Data entry experience.


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