Aetna Sr. Claim Benefit Specialist in Plymouth, Minnesota

Req ID: 51917BR


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:

Reviews pre-specified claims or claims that exceed specialist adjudication authority or processing expertise.

Applies medical necessity guidelines, determines coverage, complete eligibility verification, identify discrepancies and applies all cost containment measures to assist in the claim adjudication process.

Handles phone and written inquires related to requests for pre-approvals/pre authorizations, reconsiderations or appeals.

Ensures all compliance requirements are satisfied and that all payments are made against the company practices and procedures.

Identifies and reports possible claim overpayments, underpayments and any other irregularities.

Performs claim re-work calculations.


Experience in a production environment.

Claim processing experience.


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


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 and 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.

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