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

Claim Benefit Specialist

Primary Location: Tampa, Florida
Additional Locations: FL-Tampa
Please join us for an Open House
On: Saturday 7/27/19
Walk-In Interviews will take place at
4630 Woodland Corporate Blvd
From: 9am - 2pm
Please bring multiple copies of your resume!

Reviews and adjudicates Medicare medical claims in accordance with CMS claim processing guidelines. Role requires strong keyboard skills, attention to detail and the ability to work independently in a production environment.

Fundamental Components:
The Claim Benefit Specialist position is a production-based role servicing Medicare Advantage beneficiaries. 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. 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 based environment with an emphasis on quality outcomes
  • Medical claim processing experience is preferred
  • Strong computer navigational skills, Medicare experience, medical terminology and coding certification are desirable
  • 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.

Required Skills:
General Business - Maximizing Work Practices, Service - Demonstrating Service Discipline, Service - Providing Solutions to Constituent Needs

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

Functional Skills:
Claim - Claim processing - Medical - Medicare

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

Click To Review Our Benefits (PDF)


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