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Senior Claim Benefit Specialist

Primary Location: Phoenix, AZ
Additional Locations: AZ-Phoenix
  • Reviews and adjudicates complex, sensitive, and/or specialized claims in accordance with claim processing guidelines.
  • Acts as a subject matter expert by providing training, coaching, or responding to complex issues.
  • May handle customer service inquiries and problems.

Fundamental Components:
  • Reviews pre-specified claims or claims that exceed specialist adjudication authority or processing expertise.
  • Applies medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and apply all cost containment measures to assist in the claim adjudication process.
  • Handles phone and written inquiries related to requests for pre-approvals/pre-authorizations, reconsiderations, or appeals.
  • Ensures all compliance requirements are satisfied and that all payments are made against company practices and procedures.Identifies and reports possible claim overpayments, underpayments and any other irregularities.
  • Performs claim re-work calculations.Distributes work assignments daily to junior staff.
  • Trains and mentors claim benefit specialists.Makes outbound calls to obtain required information for First claim or re-consideration.
  • Trained and equipped to support call center activity if required, including general member and/or provider inquiries.

Background Experience:
  • Experience in a production environment.
  • Demonstrated ability to handle multiple assignments competently, accurately and efficiently.
  • 2+ years claim processing experience.
  • Claim processing experience.
  • Associate's degree or equivalent work experience.

Additional Job Information:
Understanding of medical terminology.Strong knowledge of benefit plans, policies and procedures.Oral and written communication skills.Ability to maintain accuracy and production standards.Technical skills.Analytical skills.

Potential Telework Position:

Percent of Travel Required:

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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