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Claims Manager, Shanghai - 58210BR

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

The global operations team is responsible for delivering world-class service to our members, internal customers and providers.We are the face of Aetna and provide 24x7 global support, front line customer services, claims and product expertise.

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

Position Summary/Mission:

Member and provider claim adjudication

Claim administration, including the handling of member and provider claim documentation, and liaison with China fronting companies for claim reimbursement.

Network operations, including the management of the Direct billing network provider reconciliation and the public hospital representative team

Claim data analytics and reporting, claim system issue resolution and UAT support

Fundamental Components & Physical Requirements

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

Ensures that performance evaluations and compensation decisions for employees are not influenced by the financial outcomes of claims decisions.

(*) Has responsibility for claim financial results by promoting competent claim and risk management of multi-million-dollar book of business.

Challenges and motivates staff to be responsive to performance expectations in a rapidly changing work environment. Assesses business requirements and assigns team resources to support new business implementations; collaborates with implementation manager, plan sponsors, consultants and sales to ensure strong customer satisfaction and meet product objectives. Serves as an agent to drive change across the organization; communicates workflow results, ideas and solutions.

Initiates, develops and manages quality improvement and claim management programs.

Implements appropriate revisions to business performance measures.

Incorporates unit results into performance evaluations and reward systems.

Develops and participates in presentations to internal and external customers.

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

Assesses individual and team performance on a regular basis and provides candid and timely developmental feedback. Develops training plans and ensure training needs are met.

Establishes a clear vision aligned with company values. 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 a cohesive team that works well together.

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

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

Ensures regulatory compliance with policies and procedures.

Enforces authority limit policy and procedure.

Uses critical thinking and extensive knowledge of Aetna systems and processes to evaluate impact of customer requested exceptions and develops reasonable alternatives to satisfy clients’ needs while minimizing impact on Aetna systems and operations.

Actively contributes to the decision-making process that impacts profitability and retention of business when collaborating on review, analysis and development of recommendations for the design of complex account and benefit structures based on customers’ objectives and Aetna systems.

Coordinates resources to ensure a successful case installation of new products and services.

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

Delivers organized polished presentation of solutions with benefits tied to constituent needs.

Identifies and analyzes the impact from both upstream and downstream contributors to problems, and then partners extensively across business functions to proactively resolve developing service delivery issues.

Background/experience desired:

University level of education or higher.Equivalent qualification and/or experience may be considered.

Experience in an insurance and/or health care environment is essential.

Demonstrable success in a claim team management role for minimum of 3 years prior.

Fluent written and spoken English with second language being desirable.

Additional information:

You’ll need to demonstrate the following:

A passion for providing outstanding customer experience.Excellent listening skills.

An ability to solve complex challenges.Self-motivation with an ability to work on your own initiative

Effective collaboration and team working.A high degree of accuracy and a keen eye for detail

High levels of organizational skills with the ability to prioritize and multi-task.

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

Eager to work in a high energy, fast-paced business, where change is a constant


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

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