Family Summary/Mission:
Achieve superior claim and member service performance through an integrated process of operational, quality, medical cost, and resource management meeting and/or exceeding member, plan sponsor, and provider expectations.

Position Summary/Mission:
Reviews and adjudicates claims in accordance with claim processing guidelines

Fundamental Components & Physical Requirements:
Analyzes and approves Claims
Applies medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and applies all cost containment measures to assist in the claim adjudication process
Coordinates responses for phone inquiries and written correspondence related to claim processing issues
Routes and triages High $ claims and seeks support and advice from designated Specialists. (Senior Claim Benefits Specialist)
Proofs claim or referral submission to determine, review, or apply appropriate guidelines, coding, member identification processes, provider selection processes, claim coding, including procedure, diagnosis and pre-coding requirements
Investigate claims for possible abuse and fraud
May facilitate training when considered topic subject matter expert
In accordance with prescribed operational guidelines, manages claims on desk, route/queues, and all systems within specified turn-around-time parameters
Utilizes all applicable system functions available ensuring accurate and timely claim processing service (i.e., use of all documented resources)
Escalate unresolved claims complaints and high costs claims to the claims supervisor for guidance
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 behaviors outlined in Claim Benefit Specialist Competencies
Report preparation with all database daily, weekly and monthly according to different kinds of request from internal & external request

Background/Experience Desired:
Experience in a production environment..
Claim processing experience
Data Entry Experience

Educational Requirements:
High School graduate or local market equivalent
Additional Information (not mandatory to complete):
Ability to maintain accuracy and production standards
Analytical skills
Technical skills
Excellent oral and written communication skills
Understanding of medical terminology

安态（上海）企业服务有限公司是美国安泰集团在中国的全资子公司。美国安泰集团公司（纽约证券交易所代号: AET，以下简称安泰集团） 始创于1853年，全球总部位于美国康涅狄格州哈特福德市，是美国历史最悠久的金融保险集团之一，也是全球财富500强企业，2010年营业收入超过342亿美金。

跨入21世纪，安泰集团已发展成为国际领先的专业健康福利保障公司，业务范围涵盖健康保险产品及相关服务，其中包括医疗、药物、牙科、行为健康、团体人寿和伤残计划，以及针对公共医疗补助计划的医疗管理功能和保健管理服务。

安泰集团在全球聘用了超过35000名员工，包括执业医师、护士、药剂师及其他临床专业人士。作为健康福利保障业的翘楚，我们的客户包括员工团体、个人、大学学生、兼职和小时工、健康计划、资助计划、劳工组织及外籍人员。

2008年3月，安泰集团被美国财富杂志推选为美国最值得推崇的健康福利保障公司。同年，安泰集团也被美国商业周刊杂志推选为最适合开展职业生涯的公司之一。

安态（上海）企业服务有限公司致力引进美国先进的健康管理理念与技术，为中国市场企业客户提供高质量的健康管理服务和健康保险外包服务。

更多信息，请登陆公司网站：
www.aetna.com

Aetna (Shanghai) Enterprise Services Co. Ltd is a wholly owned enterprise of Aetna Inc. Aetna (NYSE: AET) was established in 1853 with headquarter in Hartford, CT, USA. As a global Fortune 500 company, Aetna is a well-known finance – insurance group in the US. Its 2010 revenue exceeded USD 34.2 billion.

Entering into the 21st century, Aetna now is a leading provider of health and related benefits programs, covering health insurance products and related services, including medical, pharmacy, dental, behavioral health, group life and disability plans, and medical management capabilities and health care management services for Medicaid plans.

Aetna has over 35,000 employees worldwide, including licensed physicians, nurses, pharmacists and other clinic staff. Being the leading health-related benefit provider, Aetna’s customers include employer groups, individuals, college students, part-time and hourly workers, health plans, governmental units, government-sponsored plans, labor groups and expatriates.

In 2008, Aetna was ranked 1st in Fortune's 2008 Most Admired Health Care Company and was also recognized as one of the "Best Places to Launch a Career" in 2008 by Business Week.

Aetna (Shanghai) Enterprise Services Co. Ltd aims to introduce international concepts and practice of health management services into China to provide high quality health management services.

For more information, please visit our website:
www.aetnainternational.com