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Medical Claim Processor

Primary Location: High Point, NC
Additional Locations: NC-High Point
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Description:
At Aetna, we are currently recruiting analytical, detail oriented and caring and curious claim processors who are willing to be problem solvers and champions for our members’ best health to help guide the members along a clear path to care. We work to build trust with our members and take pride in doing the right thing for the right reason. If you are passionate and empathetic about the people you serve and have a medial claim processing background with attention to detail and accuracy, this position may be a fantastic career opportunity for you!

Fundamental Components:
Claim Benefit Specialist (CBS). CBS build a trusting relationship with the member by analyzing and processing claims accurately and timely in accordance with prescribed operational claim processing guidelines. They take accountability to fully understand the members’ benefit coverage, complete eligibility verification, identify discrepancies and apply all cost containment measures. CBS coordinates responses for routine phone inquiries and written correspondence related to claim processing. They have knowledge of policy, procedure and resources to comply with regulatory guidelines.
  • Analyzes and approves 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.
  • 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.
  • 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:
To be successful, CBS require experience in a production environment and medical claim processing experience.
  • Strong analytical and technical skill with ability to maintain accuracy and production standards.
  • Understanding of medical terminology with strong attention to detail and accuracy.
  • Ability to multitask, prioritize, problem-solve and effectively adapt to a fast-paced, changing environment.
  • Excellent written, oral communication and computer skills.
  • Top candidates will possess critical thinking, technical skills, professionalism and understanding of medical terminology with prior medical claim processing experience preferred.
  • Ability to use multiple computer applications at one time.


Additional Job Information:

Our Claim Processors are very important first line of contact with the customers. Our claim processing team consists of talented, dedicated people with the skills to make a difference in the lives of our customers. The setting is fast-paced, and customer satisfaction is a top priority. People who thrive in our organization can handle multiple tasks while maintaining positive and professional outlook. Our work environment is engaging and diverse. Employees are encouraged to satisfy professional ambitions, take pride in their contributions and share in our success.

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 the 20 week training period is required. After completion of the training period, overtime may be required based on business needs.



Required Skills:
General Business - Maximizing Work Practices, Service - Demonstrating Service Discipline, Technology - Leveraging Technology

Desired Skills:
General Business - Communicating for Impact, Service - Creating a Differentiated Service Experience

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

Potential Telework Position:
No

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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