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Claim Benefit Specialist
at Aetna
San Diego, CA

Claim Benefit Specialist
at Aetna
San Diego, CA

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Description

Description: Reviews and adjudicates routine claims in accordance with claim processing guidelines. Fundamental Components:
  • 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).
Background Experience:
  • Experience in a production environment.
  • 1-3 years Claim processing experience.
  • Microsoft Excel and Access experience.
  • High School or GED equivalent.
Additional 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.
Required Skills: General Business - Applying Reasoned Judgment, General Business - Consulting for Solutions, General Business - Maximizing Work Practices Desired Skills: General Business - Turning Data into Information, Service - Handling Service Challenges, Technology - Leveraging Technology Functional Skills: Claim - Claim processing - Medical or Hospital- HMO, Claim - Claims Administration - coordination of benefits (COB) verification, Claim - Payment management Potential Telework Position: No Percent of Travel Required: 0 - 10% EEO Statement: Aetna is an Equal Opportunity, Affirmative Action Employer Benefit Eligibility: Benefit eligibility may vary by position. Click here to review the benefits associated with this position. Candidate Privacy Information: 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.

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