Job Description

Job Description
Handles end-to-end processes associated with claim data management. Identifies and addresses issues impacting auto-adjudication levels and claim accuracy. May complete manual plan-set-up activities associated with new business/account implementations.
Performs as Subject Matter Expert for the team relative to complex set-up, processing, system, policies and/or department workflows, meeting internal/external deadlines for production and quality of various products and services.
Analyzes and determines if products and services selected by customers are aligned with their benefit needs, and can be adequately supported through existing systems or operating platforms; alternately, seeks solutions and negotiate essential requirements in support of any non-standard plan selections.
Presents information effectively to various levels of employees and management through various formats, i.e. one on one, staff/customer meetings, presentations, etc.
Provides supervisory back up and assists in the delegation of issues and proposes streamlined workload assignments.
Leads process improvement initiatives to improve productivity, accuracy and/or customer service and tool development. Manages assigned projects and ensures project plans and/or work tasks align with overall organizational goals.
Assists with the development and testing of new or enhanced product offerings as assigned. Mentors other employees associated with claim data management (e.g. provides technical expertise to team/unit).Assists with the development, delivery and implementation of training tools and processes.
May be responsible for training staff on transplant claim processing and the administration of the Institutes of Excellence (IOE) contracts and Letters of Agreement (LOA) for accurate review and application of the negotiated rates for these claims. Exhibits behaviors outlined in Claim Data Specialist Competencies

Required Qualifications
Minimum of one year of recent and related direct CLAIMS experience.
Minimum of three years of recent and related ACAS Plan Setup Experience.
Minimum one year of recent and related Aetna claim processing experience.
Proficiency in all claim platforms and/or products, i.e. Traditional, HMO, Medicaid, HNO High school diploma or equivalent work experience required.
Intermediate/advanced excel
Certified Professional Coder (CPC) Preferred

Preferred Qualifications
Excel knowledge and claims/coding background

Education
High School diploma, G.E.D. or equivalent experience

Business Overview
At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.

We are committed to maintaining a diverse and inclusive workplace. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.