Remote Health Insurance Claims Analyst

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The Opportunity

Aetna, a CVS Health company, is one of the nation's premier health insurance providers, serving over 39 million members across commercial, Medicare, and Medicaid plans. We are currently seeking a Remote Health Insurance Claims Analyst to join our Claims Operations team. In this role, you will be responsible for the accurate adjudication of health insurance claims, ensuring members and providers receive timely and correct reimbursements. You will thrive in this role if you have a sharp eye for detail, a solid understanding of health insurance processes, and a commitment to regulatory compliance.

Your Day-to-Day

  • Adjudicate commercial, Medicare Advantage, and Medicaid claims in accordance with plan benefits and Aetna processing guidelines
  • Review claims for completeness, eligibility, authorization requirements, and coding accuracy
  • Identify and process claim adjustments, voids, and resubmissions as needed
  • Investigate coordination of benefits scenarios and apply correct payment sequencing
  • Respond to provider and member inquiries regarding claim status, denials, and appeal rights
  • Monitor and meet daily production and quality accuracy targets
  • Flag potential fraud, waste, and abuse patterns for Special Investigations Unit review
  • Maintain thorough documentation of all claims actions in Aetna's claims management system

Who You Are

  • You have 2+ years of experience in health insurance claims processing or adjudication
  • You are proficient in reading and applying Explanation of Benefits (EOB), Remittance Advice (RA), and plan documents
  • You understand ICD-10, CPT, and HCPCS coding and their role in claims review
  • You are familiar with Medicare Secondary Payer rules and coordination of benefits guidelines
  • You have strong analytical skills and can work independently in a remote, high-volume environment
  • You hold a high school diploma or GED; a degree in health information management or business is preferred

Benefits & Perks

  • Competitive hourly pay with shift differential opportunities
  • Aetna medical, dental, and vision insurance starting day one
  • 401(k) savings plan with employer match up to 6%
  • Paid time off, paid holidays, and bereavement leave
  • Employee Assistance Program (EAP) and mental health resources
  • Opportunities for internal advancement within Aetna's Claims and Health Services divisions
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