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Senior Claims Research Specialist

Primary Location: Naperville, IL
Additional Locations: IL-Naperville
Handles end-to-end processes associated with claim data management. Identifies and addresses issues impacting auto-adjudication levels and claim accuracy. May complete manual plan-set-up activities associated with new business/account implementations.

Fundamental Components:
  • Performs as Subject Matter Expert for the team relative to complex set-up, processing, system, policies and/or department workflows, meeting internal/external deadlines for production and quality of various products and services.
  • Analyzes and determines if products and services selected by customers are aligned with their benefit needs, and can be adequately supported through existing systems or operating platforms; alternately, seeks solutions and negotiate essential requirements in support of any non-standard plan selections.
  • Presents information effectively to various levels of employees and management through various formats, i.e. one on one, staff/customer meetings, presentations, etc.
  • Provides supervisory back up and assists in the delegation of issues and proposes streamlined workload assignments.
  • Leads process improvement initiatives to improve productivity, accuracy and/or customer service and tool development.
  • Manages assigned projects and ensures project plans and/or work tasks align with overall organizational goals.
  • Assists with the development and testing of new or enhanced product offerings as assigned.
  • Mentors other employees associated with claim data management (e.g. provides technical expertise to team/unit).
  • Assists with the development, delivery and implementation of training tools and processes.
  • May be responsible for training staff on transplant claim processing and the administration of the Institutes of Excellence (IOE) contracts and Letters of Agreement (LOA) for accurate review and application of the negotiated rates for these claims.
  • Exhibits behaviors outlined in Claim Data Specialist Competencies

Background Experience:
  • Minimum of one year of recent and related direct customer service experience
  • Minimum of three years of recent and related ACAS Plan Setup Experience.Minimum one year of recent and related Aetna claim processing experience.
  • Proficiency in all claim platforms and/or products, i.e. Traditional, HMO, HNO High school diploma or equivalent work experience required

Additional Job Information:
  • Excellent written and oral communication skills.
  • Ability to work collaboratively within work teams.
  • Ability to manage multiple priorities.
  • Highly organized and able to quickly prioritize multiple assignments with high quality results.
  • Knowledge of Aetna systems and products.
  • Strong customer service skills.
  • Ability to interact with different groups of people at different levels and provide assistance on a timely basis.
  • Analytical skills.

Clinical Licensure:

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.

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.


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