Research and Adjustment Analyst

About Our Company
We are a company built on excellence. We have a culture that values growth, achievement and diversity and a workplace where your voice can be heard.

POSITION SUMMARY
Reviews and adjudicates complex, sensitive, and/or specialized claims in accordance with claim processing guidelines. Acts as a subject matter expert by providing training, coaching, or responding to complex issues. May handle customer service inquiries and problems.

ADDITIONAL JOB INFORMATION
- Accurately adjudicate claims in accordance with health plan guidelines, company standards, and company procedures 8+ lines of business (this includes all types of claims inventory, i.e., COB, Pends, Quality Review claims, Unfinished Claims Report, and Adjustments)
- Determines reason for refund/adjustment received
- Assesses need of corrective measures
- Completes adjustment as per department standards and policies
- Identifies configuration, processing and billing issues; facilitate resolution
- Liaises with appropriate departments to conduct proper claims action
- Develops, establishes, and maintains a work priority system to ensure daily and heavy workloads are fulfilled
- Maintains minimum production and quality standards

Required Skills:
EDUCATION
The highest level of education desired for candidates in this position is a High School diploma, G.E.D. or equivalent experience.

REQUIRED SKILLS
- Adjudicate claims in compliance with HIPAA guidelines
- Must have effective oral and written communication abilities
- ability to multi-task; must possess effective organizational skills
- Capacity to establish and maintain constructive business relationships with internal/external customers while maintaining integrity and confidentiality
- Aptitude to research, analyze and successfully resolve a broad spectrum of issues
- Intermediate skill level with Word and Excel required
- Must be able to operate effectively as a team member, and be able to manage project time constraints and work with little supervision
- Experience in claim adjudication with an automated claim processing system
- Must have a minimum of three years basic claims processing experience in a Managed Care Organization (MCO)
- At least one year s advanced claims processing experience, including COB/TPL, reversals, appeals, grievances, special handling, analysis, and research
- Working knowledge of Medicaid, Medicare, Self-funded, and commercial insurance

Schaller Anderson is an affiliate of Aetna.  We value leadership, creativity and initiative. If you share those values and a commitment to excellence and innovation, consider a career with our company.

To learn more about this opportunity, visit us at www.aetna.com/working . Under requisition # select 25194 and submit your resume.

Please note that benefit eligibility may vary by position. Click here to review the benefits associated with this position.

We conduct pre-employment drug and background testing.
No agencies, please.


We are an equal opportunity/affirmative action employer.