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A new day in healthcare. Together, CVS Health and Aetna help people on their path to better health.

Claim Benefit Specalist

Primary Location: Fresno, California
Additional Locations: CA-Fresno
Reviews and adjudicates routine claims in accordance with claim processing guidelines. Critical success factors - Ability to work independently - Ability to think logically and problem solve - Strong oral communication skills

Fundamental Components:
Analyzes and approves routine claims that cannot be auto adjudicated. Applies medical necessity guidelines, determines coverage, completes eligibility verification, identifies discrepancies, and applies all cost containment measures to assist in the claim adjudication process. 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

Background Experience:
Experience in a production environment.
Claim processing experience.
High School or GED equivalent.

Additional Job Information:

Understanding of medical terminology.
Oral and written communication skills.
Ability to maintain accuracy and production standards.
Technical skills.
Attention to detail and accuracy.
Analytical skills.

to play a role in an emerging and rapidly growing healthcare market. 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. Work at home is only available for current WAH employees if the new
position’s telework criteria is met. Telework status may change, with advance
notice, based on strategic business decisions.

Required Skills:
Service - Demonstrating Service Discipline, Service - Improving Constituent-Focused Processes, Service - Providing Solutions to Constituent Needs

Desired Skills:
General Business - Applying Reasoned Judgment, General Business - Demonstrating Business and Industry Acumen, General Business - Maximizing Work Practices

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

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

Potential Telework Position:

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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