Claim Benefit Specialist

Job Description

Description: Summary/Mission
The global operations team is responsible for delivering world-class service to our members, internal customers, and providers. We are the face of Aetna and provide 24x7 global support, front line customer services, claims, and product expertise.
We believe that a positive member experience starts with investment in our people. Our aim is to communicate with our customers on their terms, through local teams, in local languages. We want to know our customers, own our relationships with them, predict their needs and meet them proactively. We ensure our members get the healthcare they need, when they need it, with maximum value and minimum effort.
As a member of our claims team, you will achieve the superior claim and member service performance through an integrated process of operational, quality, medical cost, and resource management, responsible for claims handling end-to-end.
Position Summary/Mission
Claims representatives are naturally caring and empathetic but also keen problem solvers who take ownership of customer needs using their extensive knowledge, training, expertise and passion to navigate customers through their healthcare journey.
Specifically, you will review and adjudicates claims in accordance with claim processing guidelines. Answer queries on the claims handling process and specific claims, whether those questions come from members directly, internal operations teams, account management teams, or brokers.
Fundamental Components & Physical Requirements include but are not limited to

• Analyzes and approves claims.
• Completes work with a limited degree of supervision
• Assesses claims up to given Authority limit
• Seek advice from designated Specialists on complicated cases or claims above authority limit. (Senior Claim Benefits Specialist and Claim Supervisor/Manager).
• 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.
• Identify and 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.
• Utilizes all applicable system functions available ensuring accurate and timely claim processing service (i.e., use of all documented resources).
• Comprehend with complex workflows and come up with a customer-centric solution within reasons
• 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.

As a Claims Representative you will;

• Develop knowledge, skills and experience in a variety of Operational disciplines and processes
• Display fantastic oral and written communication skills
• Establish relationships with internal and external customers
• Act proactively, take ownership of problems and be empowered to take actions to resolve our members' concerns.
• Be resilient and adaptable to changes in priorities, distressed customers or high volumes
• Deliver an experience, not just a service

Background/Experience Desired

• 2 years’ experience in a healthcare claims environment.
• Claim assessment experience.
• Requires specialized skills in one area or a breadth of knowledge across multiple areas.

Education and Certification Requirements

• High School graduate or local market equivalent.
• Certificate in Basic Insurance Concepts and Principles (BCP)

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.

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EEO Statement: Aetna is an Equal Opportunity, Affirmative Action Employer