Aetna Claim Benefit Specialist in Fresno, California

Req ID: 53329BR

POSITION SUMMARY

Achieve superior claim and member service performance through an integrated process of operational, quality, medical cost, and resource management meeting and/or exceeding member, plan sponsor, and provider expectations. 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 desired:

  • Experience in a production environment.

  • Claim processing experience.

  • Ability to maintain accuracy and production standards.

  • Analytical skills.

  • Technical skills.

  • Oral and written communication skills.

  • Understanding of medical terminology.

  • Attention to detail and accuracy.

EDUCATION

The highest level of education desired for candidates in this position is a High School diploma, G.E.D. or equivalent experience.

ADDITIONAL JOB INFORMATION

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 candidates'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

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.