Claim Benefit Specialist


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Claim Benefit Specialist

Claim Benefit Specialist areas represent the “face” of Aetna, serving as the important first line of contact with our customers. These professionals work directly with our members, doctors and employer groups (companies) to help them better understand our products and services and assist with timely, accurate payment of their claims, while providing a human connection at those times when it is needed most. Employees who are part of our customer service team are talented, dedicated individuals with the skills to make a difference in the lives of our customers.


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.

Position Summary:

Reviews and adjudicates routine claims in accordance with claim processing guidelines.

Fundamental Components & Physical Requirements include but are not limited to:

•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.

Background/Experience Required:

•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 and Certification

High School or GED equivalent.