Aetna Sr Claim Benefit Spec in Tampa, Florida

Req ID: 37739BR


Reviews and adjudicates complex, sensitive, and/or specialized claims in accordance with claim processing guidelines. Responds to complex issues, handles customer service inquiries and problems.

Fundamental Components:

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. () Makes outbound calls to obtain required information for First claim or re-consideration. (*)


2+ years claim processing experience.

Experience in a production environment.

Claim processing experience.

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


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 or Hospital- HMO/1-3 Years

Functional - Customer Service/Customer Service - Member Services - Traditional products/1-3 Years

Functional - Products-Medical/Self Funded HMO/QPOS/USAccess/1-3 Years

Functional - Products-Medical/Fully Insured Dependents Out of Area Plans/1-3 Years


General Business/Communicating for Impact/FOUNDATION

Leadership/Driving a Culture of Compliance/FOUNDATION

Service/Working Across Boundaries/FOUNDATION


Leadership/Driving Change/ADVANCED

Service/Handling Service Challenges/ADVANCED

Service/Demonstrating Service Discipline/FOUNDATION

Telework Specifications:

Would prefer in-office if close to the office. Otherwise, work at home will be an option. Would like to fill position within Plymouth, Amherst, Tampa, Wisconsin


Ability to maintain accuracy and production standards. Analytical skills. Technical skills. Oral and written communication skills. Understanding of medical terminology. Strong knowledge of benefit plans, policies and procedures.

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.

Job Function: Claim