Aetna Claim Benefit Specialist in Farnborough, United States
Req ID: 52335BR
About AetnaAetna are a leading diversified health care benefits company, serving an estimated 37 million people. We offer industry-leading information, tools and resources to help people achieve their best possible health. Our team of 71,000 healthcare professionals is committed to creating a better healthcare experience and access to quality health management solutions for our customers. Aetna is about more than just doing a job. This is our opportunity to re-shape healthcare across the globe. We are a company built on excellence. We have a culture that values growth, achievement and diversity and a workplace where your voice can be heard. Join us and help turn health ambitions into achievements. Role SummaryAn exciting opportunity has become available to join our team as a Claim Benefit Specialist. We are looking for the right talent to join our lively and energetic team where the collective aim is to always achieve superior claim and member service performance and exceed customer expectations. Responsibilities of the Role• Analyses and approves claims.• Completes work with a limited degree of supervision• Assesses claims up to given Authority limit• 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.• Investigate claims for possible abuse and fraud.• Conducts outreach activities including but not limited to email, member calls, provider calls as part of the claims adjudication process• In accordance with prescribed operational guidelines, manages claims on desk, route/queues, and all systems within specified turn-around-time parameters.• Utilises all applicable system functions available ensuring accurate and timely claim processing service (i.e., use of all documented resources).• Escalate unresolved claims complaints and high costs claims to the claims supervisor for guidance.• Continually work to improve best practices procedures and standards.• Ensures compliance with requirements of regional compliance authority/industry regulator.• Adheres to international privacy policies, practices and procedures. Background/Experience Desired• Experience of working in a healthcare claims environment.• Claim assessment experience.• Requires specialized skills in one area or a breadth of knowledge across multiple areas Additional Information (situational competencies, skills, work location requirements, etc.)• Ability to maintain accuracy and production standards.• Analytical skills.• Technical skills.• Excellent communication skills.• Oral and written communication skills.• Understanding of medical terminology.
Job Function: Claim