Aetna Claim Benefit Specialist in Houston, Texas

Req ID: 43680BR

Candidate must work full time from the Houston, TX office; Telework will be evaluated on a case by case basis.


Reviews and adjudicates Aetna Medicare claims in accordance with Aetna/CMS claim processing guidelines.

Fundamental Components:

Analyzes and approves routine claims that cannot be auto adjudicated in accordance with Aetna and CMS policy guidelines

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 documentation systems within specified turn-around-time parameters

Utilizes all applicable system functions available ensuring accurate and timely claim processing service


Claims processing experience would be highly preferred.

Experience using IDX/Coventry platforms is highly preferred.

Ability to maintain accuracy and production standards.

Analytical skills.

Technical skills.

Oral and written communication skills.


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


Functional - Claims/Claim processing - Medical - Medicare/1-3 Years


Technical - Desktop Tools/Microsoft Outlook/1-3 Years/End User

Technical - Desktop Tools/Microsoft Word/1-3 Years/End User


Service/Handling Service Challenges/FOUNDATION

Service/Providing Solutions to Constituent Needs/FOUNDATION

General Business/Maximizing Work Practices/FOUNDATION


General Business/Communicating for Impact/FOUNDATION

Service/Creating a Differentiated Service Experience/FOUNDATION

Telework Specifications:

Option for telework will be evaluated after a certain period of employment

Telework considered only for unique circumstances


Aetna is about more than just doing a job. This is our opportunity to re-shape healthcare for America and across the globe. We are developing solutions to improve the quality and affordability of healthcare. What we do will benefit generations to come.

We care about each other, our customers and our communities. We are inspired to make a difference, and we are committed to integrity and excellence.

Together we will empower people to live healthier lives.

Aetna is an equal opportunity & affirmative action employer. All qualified applicants will receive consideration for employment regardless of personal characteristics or status. We take affirmative action to recruit, select and develop women, people of color, veterans and individuals with disabilities.

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.

Benefit eligibility may vary by position. Click here to review the benefits associated with this position.

Aetna takes our candidate's data privacy seriously. At no time will any Aetna recruiter or employee request any financial or personal information (Social Security Number, Credit card information for direct deposit, etc.) from you via e-mail. Any requests for information will be discussed prior and will be conducted through a secure website provided by the recruiter. Should you be asked for such information, please notify us immediately.

Job Function: Claim