Aetna Senior Claim Benefit Specialist in Phoenix, Arizona
Req ID: 65571BR
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.
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.
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.