Claim Benefit Specialist
Posted on: 6 Apr 2021
Jacksonville, FL
Job Description
Job Description
- 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.
- Reviews prespecified 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 preapprovals/preauthorizations, 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.
Required Qualifications
- 2+ years claim processing experience.
- Knowledge of medical and hospital claims.
- Problem solving ability.
- Must be Productive.
- Must have analyzation skills.
Preferred Qualifications
- Experience in a production environment.
- Medical claim coding is a plus.
- Demonstrated ability to handle multiple assignments competently, accurately and efficiently.
Education
- Associate's degree or equivalent work experience.
Business Overview
At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.
We are committed to maintaining a diverse and inclusive workplace. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.
Aetna
Hartford, CT
Aetna Inc. operates as a health care benefits company in the United States. It operates through three segments: Health Care, Group Insurance, and Large Case Pensions. The Health Care segment offers medical, pharmacy benefit management service, dental, behavioral health, and vision plans on an insured and employer-funded basis. It also provides point-of-service, preferred provider organization, health maintenance organization, and indemnity benefit plans, as well as health savings accounts and consumer-directed health plans.
In addition, this segment offers Medicare and Medicaid products and services, as well as other medical products, such as medical management and data analytics services, medical stop loss insurance, workers’ compensation administrative services, and products that provide access to its provider networks in select geographies. The Group Insurance segment offers life insurance products, including group term life insurance, voluntary spouse and dependent term life insurance, group universal life insurance, and accidental death and dismemberment insurance; disability insurance products; and long-term care insurance products, which provide the benefits to cover the cost of care in private home settings, adult day care, assisted living, or nursing facilities.
The Large Case Pensions segment manages various retirement products comprising pension and annuity products primarily for tax-qualified pension plans. The company provides its products and services to employer groups, individuals, college students, part-time and hourly workers, health plans, health care providers, governmental units, government-sponsored plans, labor groups, and expatriates. Aetna Inc. was founded in 1853 and is based in Hartford, Connecticut. As of November 28, 2018, Aetna Inc. operates as a subsidiary of CVS Pharmacy, Inc.
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IndustryInsurance
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No. of Employees47,950
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Website
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Jobs Posted12677
