Aetna Veterans Jobs

Job Information

Aetna Senior Claim Benefit Specialist in Phoenix, Arizona

Req ID: 65571BR

Job Description

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.

Fundamental Components included but are not limited to:

  • Reviews pre-specified claims or claims that exceed specialist adjudication authority or processing expertise.

  • Applies medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and apply all cost containment measures to assist in the claim adjudication process.

  • Handles phone and written inquiries related to requests for pre-approvals/pre-authorizations, reconsiderations, or appeals.

  • Ensures all compliance requirements are satisfied and that all payments are made against company practices and procedures.

  • Identifies and reports possible claim overpayments, underpayments and any other irregularities.

  • Performs claim re-work calculations.

  • Distributes work assignments daily to junior staff.

  • Trains and mentors claim benefit specialists.

  • Makes outbound calls to obtain required information for First claim or re-consideration.

  • Trained and equipped to support call center activity if required, including general member and/or provider inquiries.

Qualifications Requirements and Preferences:

  • Experience in a production environment.

  • Demonstrated ability to handle multiple assignments competently, accurately and efficiently.

  • 2+ years claim processing experience.

  • Associate's degree or equivalent work experience.

Functional Skills:

Claim - Claims Administration - cost management

Additional Job Information:

  • Understanding of medical terminology.

  • Strong knowledge of benefit plans, policies and procedures.

  • Oral and written communication skills.

  • Ability to maintain accuracy and production standards.

  • Technical skills.

  • Analytical skills.

Benefit Eligibility

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

Job Function: Claim

Aetna 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.