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Claim Benefit Specialist

Primary Location: Bethlehem, PA
Additional Locations: PA-Bethlehem
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Description:
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:
- Experience in a production environment.Claim processing experience.
- High School or GED equivalent.

Additional Job Information:
We are looking for a customer focused individual who enjoys working in a team environment and can create value by anticipating and exceeding customer expectations. The ideal candidate will have exceptional analytical skills, accurate and fast keyboarding skills, advanced computer navigation and knowledge and experience in a Windows environment, effective verbal and written communication skills, the ability to adapt quickly and willingly to change, and a positive, willing attitude. Prior medical claim processing experience is a plus. Successful candidates should be comfortable with quality goals, production goals, and service expectations and will be monitored for accuracy, efficiency, and customer satisfaction. Comprehensive training will be provided to assist in the achievement of these objectives. Attendance during this training period is critical to your success. After completion of the training period, overtime may be required based on business needs. Attendance during the training period is critical to the success of this position. Applicants should be prepared to be present during the entire training period.

Required Skills:
General Business - Maximizing Work Practices, Service - Creating a Differentiated Service Experience, Service - Providing Solutions to Constituent Needs

Desired Skills:
Service - Demonstrating Service Discipline, Service - Handling Service Challenges, Service - Working Across Boundaries

Functional Skills:
Claim - Claim processing - Medical or Hospital - ACAS, Claim - Claim processing - Medical or Hospital- HMO

Technology Experience:
Desktop Tool - Microsoft Outlook, Desktop Tool - Microsoft SharePoint, Desktop Tool - Microsoft Word

Percent of Travel Required:
0 - 10%

EEO Statement:
Aetna is an Equal Opportunity, Affirmative Action Employer

Benefit Eligibility:
Benefit eligibility may vary by position. Click here to review the benefits associated with this position.

Candidate Privacy Information:
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.

Click To Review Our Benefits (PDF)

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