Aetna Sr Claim Benefit Spec in Amherst, New York

Req ID: 50798BR


Senior Claims Benefit Specialist should be able to process all types of medical claims including self funded and fully insured. Have the ability to work in a highly productive environment.

Fundamental Components:

Fundamental Components & Physical Requirements include but are not limited to

(* denotes essential functions)

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.

Exhibits the following Sr Claim Benefit Specialist Behaviors


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 Associate's degree or equivalent experience.


Functional - Claims/Claim processing - Medical or Hospital- HMO/1-3 Years

Functional - Claims/Payment management/1-3 Years

Functional - Customer Service/Customer service - production environment/1-3 Years

Functional - Medical Management/Medical Management - Clinical claim review/1-3 Years


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

Technical - Remote Access/WAH (Work at Home)/1-3 Years/End User


General Business/Communicating for Impact/FOUNDATION

Leadership/Driving a Culture of Compliance/FOUNDATION

Service/Working Across Boundaries/FOUNDATION


Leadership/Driving Change/ADVANCED

General Business/Maximizing Work Practices/ADVANCED

Telework Specifications:

Work at home or office based position


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