Claim Benefit Specialist

Req ID: 68060BRJob DescriptionReviews and adjudicates medical claims in accordance with claim processing guidelines. At Aetna, we are currently recruiting analytical, detail oriented and caring and curious claim processors who are willing to be problem solvers and champions for our members best health to help guide the members along a clear path to care. We work to build trust with our members and take pride in doing the right thing for the right reason. If you are passionate and empathetic about the people you serve and have a medical claim processing background with attention to detail and accuracy, this position may be a fantastic career opportunity for you!Fundamental Components included but are not limited to:

Analyzes and approves routine claims that cannot be auto adjudicated.

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 routine phone inquiries and written correspondence related to claim processing issues.

Routes and triages complex claims to 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.

May facilitate training when considered topic subject matter expert. In accordance with prescribed operational guidelines, manages claims on desk, route/queues, and ECHS within specified turn-around-time parameters (Electronic Correspondence Handling System-system used to process correspondence that is scanned in the system by a vendor).

Utilizes all applicable system functions available ensuring accurate and timely claim processing service (i.e., utilizes Claim Check, reasonable and customary data, and other post-containment tools).

Qualifications Requirements and Preferences:

Experience in a production environment.

Claim processing experience.

High School or GED equivalent.

Functional Skills:Claim - Claim processing - Medical - Behavioral HealthTechnology Experience:Desktop Tool - Microsoft Explorer, Desktop Tool - Microsoft Outlook, Desktop Tool - Microsoft WordRequired Skills:General Business - Communicating for Impact, Leadership - Driving a Culture of Compliance, Technology - Leveraging TechnologyDesired Skills:Finance - Servicing Customers Profitably, General Business - Maximizing Work Practices, Service - Handling Service ChallengesAdditional Job Information:Understanding of medical terminology.Oral and written communication skills.Ability to maintain accuracy and production standards.Technical skills.Attention to detail and accuracy.Analytical skills.Benefit EligibilityBenefit eligibility may vary by position.Job Function: ClaimAetna is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected Veterans status.