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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. Read employee reviews here
- $1000 Sign-On Bonus Austin, TX
Job Description
This position is permanent work from home in any time zone.
This position also includes a $1000 sign-on bonus as well as an additional $2000 90 days post-training! (Bonuses are only applicable to specific positions, locations, and business groups. Applicable roles have the bonus language in the job posting.)
Answers questions and resolves issues based on phone calls/letters from members, providers, and plan sponsors. Triages resulting rework to appropriate staff.
Documents and tracks contacts with members, providers and plan sponsors.
The CSR guides the member through their member's plan of benefits, Aetna policy and procedures as well as having knowledge of resources to comply with any regulatory guidelines.
Creates an emotional connection with our members by understanding and engaging the member to the fullest to champion our members’ best health.
Taking accountability to fully understand the member’s needs by building a trusting and caring relationship with the member.
Anticipates customer needs. Provides the customer with related information to answer the unasked questions, e.g. additional plan details, benefit plan details, member self-service tools, etc.
Uses customer service threshold framework to make financial decisions to resolve member issues.
Explains members’ rights and responsibilities in accordance with members' contracts. Processes claim referrals, new claim handoffs, nurse reviews, complaints (member/provider), grievance, and appeals (member/provider) via target system. Educates providers on our self-service options; Assists providers with credentialing and re-credentialing issues..members'
Responds to requests received from Aetna’s Law Document Center regarding litigation; lawsuits Handles extensive file review requests. Assists in the preparation of complaint trend report.
Assists in compiling claim data reports for customer audits. Determines medical necessity, applicable coverage provisions and verifies member plan eligibility relating to incoming correspondence and internal referrals. Handles incoming requests for appeals and pre-authorizations not handled by Clinical Claim Management.
Performs review of member claim history to ensure accurate tracking of benefit maximums and/or coinsurance/deductible. Performs financial data maintenance as necessary. Uses applicable system tools and resources to produce quality letters and spreadsheets in response to inquiries received.
] $1,000 Sign on BonusJacksonville, FL
Job Description
This position is permanent work from home for any candidate in the EST/CST time zone.
This position also includes a $1000 sign-on bonus as well as an additional $2000 90 days post-training! (Bonuses are only applicable to specific positions, locations, and business groups. Applicable roles have the bonus language in the job posting.)
Answers questions and resolves issues based on phone calls/letters from members, providers, and plan sponsors. Triages resulting rework to appropriate staff.
Documents and tracks contacts with members, providers and plan sponsors.
The CSR guides the member through their member's plan of benefits, Aetna policy and procedures as well as having knowledge of resources to comply with any regulatory guidelines.
Creates an emotional connection with our members by understanding and engaging the member to the fullest to champion our members’ best health.
Taking accountability to fully understand the member’s needs by building a trusting and caring relationship with the member.
Anticipates customer needs. Provides the customer with related information to answer the unasked questions, e.g. additional plan details, benefit plan details, member self-service tools, etc.
Uses customer service threshold framework to make financial decisions to resolve member issues.
Explains members’ rights and responsibilities in accordance with members' contracts. Processes claim referrals, new claim handoffs, nurse reviews, complaints (member/provider), grievance, and appeals (member/provider) via target system. Educates providers on our self-service options; Assists providers with credentialing and re-credentialing issues..members'
Responds to requests received from Aetna’s Law Document Center regarding litigation; lawsuits Handles extensive file review requests. Assists in the preparation of complaint trend report.
Assists in compiling claim data reports for customer audits. Determines medical necessity, applicable coverage provisions and verifies member plan eligibility relating to incoming correspondence and internal referrals. Handles incoming requests for appeals and pre-authorizations not handled by Clinical Claim Management.
Performs review of member claim history to ensure accurate tracking of benefit maximums and/or coinsurance/deductible. Performs financial data maintenance as necessary. Uses applicable system tools and resources to produce quality letters and spreadsheets in response to inquiries received.
Work from Home -$1,000 Sign-on Bonus New Albany, OH
Job Description
This position is permanent work from home for any candidate in the EST/CST time zone.
This position also includes a $1000 sign-on bonus as well as an additional $2000 90 days post-training! (Bonuses are only applicable to specific positions, locations, and business groups. Applicable roles have the bonus language in the job posting.)
Answers questions and resolves issues based on phone calls/letters from members, providers, and plan sponsors. Triages resulting rework to appropriate staff.
Documents and tracks contacts with members, providers and plan sponsors.
The CSR guides the member through their member's plan of benefits, Aetna policy and procedures as well as having knowledge of resources to comply with any regulatory guidelines.
Creates an emotional connection with our members by understanding and engaging the member to the fullest to champion our members’ best health.
Taking accountability to fully understand the member’s needs by building a trusting and caring relationship with the member.
Anticipates customer needs. Provides the customer with related information to answer the unasked questions, e.g. additional plan details, benefit plan details, member self-service tools, etc.
Uses customer service threshold framework to make financial decisions to resolve member issues.
Explains members’ rights and responsibilities in accordance with members' contracts. Processes claim referrals, new claim handoffs, nurse reviews, complaints (member/provider), grievance, and appeals (member/provider) via target system. Educates providers on our self-service options; Assists providers with credentialing and re-credentialing issues..members'
Responds to requests received from Aetna’s Law Document Center regarding litigation; lawsuits Handles extensive file review requests. Assists in the preparation of complaint trend report.
Assists in compiling claim data reports for customer audits. Determines medical necessity, applicable coverage provisions and verifies member plan eligibility relating to incoming correspondence and internal referrals. Handles incoming requests for appeals and pre-authorizations not handled by Clinical Claim Management.
Performs review of member claim history to ensure accurate tracking of benefit maximums and/or coinsurance/deductible. Performs financial data maintenance as necessary. Uses applicable system tools and resources to produce quality letters and spreadsheets in response to inquiries received.
Work from Home -$1,000 Sign-on Bonus
Job Description
This position is permanent work from home for any candidate in the EST time zone.
This position also includes a $1000 sign-on bonus as well as an additional $2000 90 days post-training! (Bonuses are only applicable to specific positions, locations, and business groups. Applicable roles have the bonus language in the job posting.)
Answers questions and resolves issues based on phone calls/letters from members, providers, and plan sponsors. Triages resulting rework to appropriate staff.
Documents and tracks contacts with members, providers and plan sponsors.
The CSR guides the member through their member's plan of benefits, Aetna policy and procedures as well as having knowledge of resources to comply with any regulatory guidelines.
Creates an emotional connection with our members by understanding and engaging the member to the fullest to champion our members’ best health.
Taking accountability to fully understand the member’s needs by building a trusting and caring relationship with the member.
Anticipates customer needs. Provides the customer with related information to answer the unasked questions, e.g. additional plan details, benefit plan details, member self-service tools, etc.
Uses customer service threshold framework to make financial decisions to resolve member issues.
Explains member’s rights and responsibilities in accordance with members' contracts. Processes claim referrals, new claim handoffs, nurse reviews, complaints (member/provider), grievance, and appeals (member/provider) via target system. Educates providers on our self-service options; Assists providers with credentialing and re-credentialing issues..members'
Responds to requests received from Aetna’s Law Document Center regarding litigation; lawsuits Handles extensive file review requests. Assists in the preparation of complaint trend report.
Assists in compiling claim data reports for customer audits. Determines medical necessity, applicable coverage provisions and verifies member plan eligibility relating to incoming correspondence and internal referrals. Handles incoming requests for appeals and pre-authorizations not handled by Clinical Claim Management.
Performs review of member claim history to ensure accurate tracking of benefit maximums and/or coinsurance/deductible. Performs financial data maintenance as necessary. Uses applicable system tools and resources to produce quality letters and spreadsheets in response to inquiries received.
$1,000 Sign on Bonus Fresno, CA
Job Description
This position is permanent work from home for any candidate in the PST time zone.
This position also includes a $1000 sign-on bonus as well as an additional $2000 90 days post-training! (Bonuses are only applicable to specific positions, locations, and business groups. Applicable roles have the bonus language in the job posting.)
Required Qualifications
Answers questions and resolves issues as a “single-point-of-contact” based on phone calls, plan sponsors, PSS/ISO, members, and providers.
Provides customized interaction based on customer preference and individualized needs, creating an emotional connection with our members by understanding and engaging the member to the fullest.
Fully understands the member’s needs by building a trusting and caring relationship with the member. Anticipates customer needs.
Provides the customer with related information to answer the unasked questions, e.g. additional plan details, benefit plan details, member self-service tools, etc.
Uses customer service threshold framework to make financial decisions to resolve member issues.
Educates and assists customers on various elements of benefit plan information and available services created to enhance the overall customer service experience with the company (i.e., assistance with member self-service tools, Consultation Opportunities – Simple Steps, Cost of Care Tools, Natural Alternatives Program, etc.).
Utilizes all relevant information to effectively influence member engagement.
Takes immediate action when confronted with a problem or made aware of a situation.
Takes ownership of each customer contact to resolve their issues and connect them with additional services as appropriate.
identifies member needs beyond the initial inquiry by answering the unasked questions.
Resolves issues without or with limited management intervention. Provides education to members to support them in managing their health.
Responds quickly to meet customer needs and resolve problems while avoiding over-committing.
Other activities may include: providing claim status information, benefit coverage interpretations, and explaining plan eligibility.
Processes claim referrals, new claim hand-offs, and escalates issues as appropriate through the system for grievances and appeals.
Initiates outreach/welcome calls to ensure constituents' expectations are met or exceeded.
$1000 Sign-On Bonus- Pittsburgh, PA
Job Description
This position includes a $1000 sign-on bonus as well as an additional $2000 90 days post-training! (Bonuses are only applicable to specific positions, locations, and business groups. Applicable roles have the bonus language in the job posting.)
This position is permanent work from home for candidates located in the EST, MST, and CST time zones with the exception of candidates close to an Aetna office. Must be willing to to work eastern hours.
If you reside in a commutable distance to our Aetna offices, the work at home option will be temporary and you will be expected to work onsite once we return to the office.
Description:
Provides targeted, personalized service based on a holistic view of the member, benefits, health information, and engagement. Handles customer service inquiries and problems via telephone, internet, web-chat or written correspondence. Engages consults and educates members by delivering individualized programs based upon the member's unique needs and preferences. Utilizes resources to assist customers in understanding components of the Aetna products including claims, accumulators, usage and balances, and cost-sharing.
Fundamental Components: – Answers questions and resolves issues as a single point of contact based on phone calls, plan sponsors, PSS/ISO, members and providers. – Provide customized interaction based on customer preference and individualized needs. – Educates and assists customers on various elements of benefit plan information and available services created to enhance the overall customer service experience with the company (i.e., assistance with Aetna Navigator, Consultation Opportunities Simple Steps, Cost of Care Tools, Natural Alternatives Program, etc). – Utilizes all relevant information to effectively influence member engagement. – Proactively assesses customer issues and anticipates their needs. – Based on the issues and customer needs, quickly determine if the member call should be extended. – Takes immediate action when confronted with a problem or made aware of a situation
Required Qualifications -Customer Service experiences are preferred, demonstrating the ability to be empathetic and compassionate. -Effective communication skills, both verbal and written -Effective organizational skills and ability to manage multiple tasks.
$1,000 Sign-on Bonus-Raleigh, NC
Job Description
This position is permanent work from home for any candidate in the EST time zone.
This position also includes a $1000 sign-on bonus as well as an additional $2000 90 days post-training! (Bonuses are only applicable to specific positions, locations, and business groups. Applicable roles have the bonus language in the job posting.)
Required Qualifications
Answers questions and resolves issues as a “single-point-of-contact” based on phone calls, plan sponsors, PSS/ISO, members, and providers.
Provides customized interaction based on customer preference and individualized needs, creating an emotional connection with our members by understanding and engaging the member to the fullest.
Fully understands the member’s needs by building a trusting and caring relationship with the member. Anticipates customer needs.
Provides the customer with related information to answer the unasked questions, e.g. additional plan details, benefit plan details, member self-service tools, etc.
Uses customer service threshold framework to make financial decisions to resolve member issues.
Educates and assists customers on various elements of benefit plan information and available services created to enhance the overall customer service experience with the company (i.e., assistance with member self-service tools, Consultation Opportunities – Simple Steps, Cost of Care Tools, Natural Alternatives Program, etc.).
Utilizes all relevant information to effectively influence member engagement.
Takes immediate action when confronted with a problem or made aware of a situation.
Takes ownership of each customer contact to resolve their issues and connect them with additional services as appropriate.
identifies member needs beyond the initial inquiry by answering the unasked questions.
Resolves issues without or with limited management intervention. Provides education to members to support them in managing their health.
Responds quickly to meet customer needs and resolve problems while avoiding over-committing.
Other activities may include: providing claim status information, benefit coverage interpretations, and explaining plan eligibility.
Processes claim referrals, new claim hand-offs, and escalates issues as appropriate through the system for grievances and appeals.
Initiates outreach/welcome calls to ensure constituents' expectations are met or exceeded.
Phoenix, AZ
Job Description
Customer Service Representative is the face of Aetna and impacts members’ service experience by the manner of how customer service inquiries and problems via telephone, internet, or written correspondence are handled. Customer inquiries are of basic and at times complex nature. Engages consults and educates members based upon the member’s unique needs, preferences, and understanding of Aetna plans, tools, and resources to help guide the members along a clear path to care.
Answers questions and resolves issues based on phone calls/letters from members, providers, and plan sponsors. Triages resulting rework to appropriate staff.
Documents and tracks contacts with members, providers and plan sponsors.
The CSR guides the member through their member's plan of benefits, Aetna policy and procedures as well as having knowledge of resources to comply with any regulatory guidelines.
Creates an emotional connection with our members by understanding and engaging the member to the fullest to champion our members’ best health.
Taking accountability to fully understand the member’s needs by building a trusting and caring relationship with the member.
Anticipates customer needs. Provides the customer with related information to answer the unasked questions, e.g. additional plan details, benefit plan details, member self-service tools, etc.
Uses customer service threshold framework to make financial decisions to resolve member issues.
Explains member’s rights and responsibilities in accordance with members' contracts. Processes claim referrals, new claim handoffs, nurse reviews, complaints (member/provider), grievance, and appeals (member/provider) via target system. Educates providers on our self-service options; Assists providers with credentialing and re-credentialing issues..members'
Responds to requests received from Aetna’s Law Document Center regarding litigation; lawsuits Handles extensive file review requests. Assists in the preparation of complaint trend reports.
Assists in compiling claim data reports for customer audits. Determines medical necessity, applicable coverage provisions and verifies member plan eligibility relating to incoming correspondence and internal referrals. Handles incoming requests for appeals and pre-authorizations not handled by Clinical Claim Management.
Performs review of member claim history to ensure accurate tracking of benefit maximums and/or coinsurance/deductible. Performs financial data maintenance as necessary. Uses applicable system tools and resources to produce quality letters and spreadsheets in response to inquiries received.
Plymouth, MN
ob Description Meritain Health’s Call Center has an opening for Customer Service Representatives. This is a work-from-home position at $17.50/ hour. This position handles customer service inquiries and problems via telephone, internet or written correspondence. Customer inquiries are of basic and routine nature.
Required Qualifications – Creating a Differentiated Service Experience – Demonstrating Service Discipline – Handling Service Challenges.
Preferred Qualifications Providing Solutions to Constituent Needs Working Across Boundaries
Education High School diploma, G.E.D. or equivalent 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.
Pittsburgh, PA
Job Description The role of the Customer Service Representative is to be a customer-focused, courteous, empathetic, service professional, who effectively uses knowledge of plans, products, procedures and systems to provide information and resolve issues, resulting in enhanced customer satisfaction and retention. The Customer Service Representative position is Aetna’s window to our members, providers, physicians, and hospitals. As a Customer Service Representative, the image you project over the telephone and how you handle the caller’s situation is the public’s perception of Aetna. We provide a human connection when it is needed most.
Required Qualifications -Experience in a production environment. -Customer Service experiences in a transaction-based environment such as a call center or retail location preferred, demonstrating the ability to be empathetic and compassionate. -Strong communication and problem-solving skills -Empathy towards customers’ needs and concerns -Strong computer navigation and typing skills -Ability to manage multiple tasks in a transaction / high volume-based environment.
New York, NY
Job Description
Meritain Health’s Call Center has multiple openings for Customer Service Representatives to support our Amherst, NY office.
-This position handles customer service inquiries and problems via telephone, internet or written correspondence.
-Customer inquiries are of basic and routine nature.
-Answers questions and resolves issues based on phone calls/letters from members, providers, and plan sponsors.
-Triages resulting in rework to appropriate staff.
-Documents and tracks contacts with members, providers and plan sponsors.
-The CSR guides the member through their member's plan of benefits, Aetna policy and procedures as well as having knowledge of resources to comply with any regulatory guidelines.
-Creates an emotional connection with our members by understanding and engaging the member to the fullest to champion for our members’ best health.
-Taking accountability to fully understand the member’s needs by building a trusting and caring relationship with the member.
-Anticipates customer needs.
-Provides the customer with related information to answer the unasked questions, e.g. additional plan details, benefit plan details, member self-service tools, etc.
-Uses customer service threshold framework to make financial decisions to resolve member issues.
-Explains member’s rights and responsibilities in accordance with the contract.
-Processes claim referrals, new claim handoffs, nurse reviews, complaints (member/provider), grievance and appeals (member/provider) via target system.
-Educates providers on our self-service options; Assists providers with credentialing and re-credentialing issues.
Indianapolis, IN
Job Description Meritain Health’s Call Center has an opening for Customer Service Representatives in our Lansing, MI office. This position handles customer service inquiries and problems via telephone, internet or written correspondence. Customer inquiries are of basic and routine nature.
Required Qualifications Creating a Differentiated Service Experience Demonstrating Service Discipline Handling Service Challenges.
Preferred Qualifications Providing Solutions to Constituent Needs Working Across Boundaries
Education High School diploma, G.E.D. or equivalent experience.
Tallahassee, FL
Answers questions and resolves issues based on phone calls/letters from members, providers, and plan sponsors. Triages resulting rework to appropriate staff.
Documents and tracks contacts with members, providers and plan sponsors.
The CSR guides the member through their member's plan of benefits, Aetna policy and procedures as well as having knowledge of resources to comply with any regulatory guidelines.
Creates an emotional connection with our members by understanding and engaging the member to the fullest to champion our members’ best health.
Taking accountability to fully understand the member’s needs by building a trusting and caring relationship with the member.
Anticipates customer needs. Provides the customer with related information to answer the unasked questions, e.g. additional plan details, benefit plan details, member self-service tools, etc.
Uses customer service threshold framework to make financial decisions to resolve member issues.
Explains members’ rights and responsibilities in accordance with members' contracts. Processes claim referrals, new claim handoffs, nurse reviews, complaints (member/provider), grievance, and appeals (member/provider) via target system. Educates providers on our self-service options; Assists providers with credentialing and re-credentialing issues..members'
Responds to requests received from Aetna’s Law Document Center regarding litigation; lawsuits Handles extensive file review requests. Assists in the preparation of complaint trend report.
Assists in compiling claim data reports for customer audits. Determines medical necessity, applicable coverage provisions and verifies member plan eligibility relating to incoming correspondence and internal referrals. Handles incoming requests for appeals and pre-authorizations not handled by Clinical Claim Management.
Performs review of member claim history to ensure accurate tracking of benefit maximums and/or coinsurance/deductible. Performs financial data maintenance as necessary. Uses applicable system tools and resources to produce quality letters and spreadsheets in response to inquiries received.
Lansing, MI
Job Description Meritain Health’s Call Center has an opening for Customer Service Representatives which will support Lansing, MI office. This is a work-from-home position at $17.50/per hour. This position handles customer service inquiries and problems via telephone, internet or written correspondence. Customer inquiries are of basic and routine nature.
Required Qualifications – Creating a Differentiated Service Experience – Demonstrating Service Discipline – Handling Service Challenges.
Preferred Qualifications – Providing Solutions to Constituent Needs – Working Across Boundaries
Education High School diploma, G.E.D. or equivalent experience.
Amherst, NY
Job Description Meritain Health’s Call Center has an opening for Customer Service Representatives in to support our New York location, This is a work from the home position at $17.50/ hour. This position handles customer service inquiries and problems via telephone, internet or written correspondence. Customer inquiries are of basic and routine nature.
Required Qualifications – Creating a Differentiated Service Experience – Demonstrating Service Discipline – Handling Service Challenges.
Preferred Qualifications – Providing Solutions to Constituent Needs – Working Across Boundaries
Education High School diploma, G.E.D. or equivalent experience.
Anchorage, AK
This position handles customer service inquiries and problems via telephone, internet or written correspondence.
-Customer inquiries are of basic and routine nature.
-Answers questions and resolves issues based on phone calls/letters from members, providers, and plan sponsors.
-Triages resulting in rework to appropriate staff.
-Documents and tracks contacts with members, providers and plan sponsors.
-The CSR guides the member through their member's plan of benefits, Aetna policy and procedures as well as having knowledge of resources to comply with any regulatory guidelines.
-Creates an emotional connection with our members by understanding and engaging the member to the fullest to champion for our members’ best health.
-Taking accountability to fully understand the member’s needs by building a trusting and caring relationship with the member.
-Anticipates customer needs.
-Provides the customer with related information to answer the unasked questions, e.g. additional plan details, benefit plan details, member self-service tools, etc.
-Uses customer service threshold framework to make financial decisions to resolve member issues.
-Explains member’s rights and responsibilities in accordance with the contract.
-Processes claim referrals, new claim handoffs, nurse reviews, complaints (member/provider), grievance and appeals (member/provider) via target system.
-Educates providers on our self-service options; Assists providers with credentialing and re-credentialing issues.
Required Qualifications
Customer Service experiences in a transaction-based environment such as a call center or retail location are preferred, demonstrating the ability to be empathetic and compassionate. Experience in a production environment. High School or GED equivalent.
Atlanta, GA
Job Description -This is an Inbound Customer Service Associate Work from the Home position. -$1000 sign-on bonus -Receives inbound calls from members or providers regarding medical precertification -Sedentary work involves significant periods of sitting, talking, and data entry. -Work requires close attention to detail to accurately follow job aids and online resources. -Utilizes multiple Aetna systems to research and review member information for eligibility and benefits and build precertification cases when required. -Performs non-medical research including eligibility verification, Coordination of Benefits, and benefits verification. -Maintains accurate and complete documentation of required information. -Utilizes effective verbal and written communication, both internally and externally, to provide first call resolution and solve complex issues. -Protects the privacy of member information and adheres to company policies regarding confidentiality. -Supports the administration of the precertification process in compliance with various laws and regulations, URAQ, and/or NCQA standards, where applicable while adhering to company policy and procedures.
Required Qualifications -At least 1 year of inbound call center experience is required. -Experience with medical terminologies such as medical office assistant, billing and coding, previous experience with a health insurance company or other clinical experience.
Charleston, WV
Job Description Customer Service agent in Medicaid call center, answering in-coming member and provider calls and responding to inquiries regarding benefits, eligibility, services, prior auth requirements, extra benefits and programs, etc. Requires high-speed internet connectivity with secure service via ethernet cable, use of WiFi is not permitted. The company provides equipment and training.
Required Qualifications Medicaid call-center experience, QNXT, SUV, PeopleSafe, and other relevant systems, ability to communicate effectively with members and providers orally and in written form, ability to meet performance standards, attendance requirements and call quality goals
Preferred Qualifications Medicaid call-center experience, QNXT, SUV, PeopleSafe and other relevant systems, ability to communicate effectively with members and providers orally and in written form, ability to meet performance standards, attendance requirements and call quality goals
Education High school diploma or equivalent
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.
Chicago, IL
Answers questions and resolves issues based on phone calls/letters from members, providers, and plan sponsors. Triages resulting rework to appropriate staff.
Documents and tracks contacts with members, providers and plan sponsors.
The CSR guides the member through their member's plan of benefits, Aetna policy and procedures as well as having knowledge of resources to comply with any regulatory guidelines.
Creates an emotional connection with our members by understanding and engaging the member to the fullest to champion our members’ best health.
Taking accountability to fully understand the member’s needs by building a trusting and caring relationship with the member.
Anticipates customer needs. Provides the customer with related information to answer the unasked questions, e.g. additional plan details, benefit plan details, member self-service tools, etc.
Uses customer service threshold framework to make financial decisions to resolve member issues.
Explains members’ rights and responsibilities in accordance with members' contracts. Processes claim referrals, new claim handoffs, nurse reviews, complaints (member/provider), grievance, and appeals (member/provider) via target system. Educates providers on our self-service options; Assists providers with credentialing and re-credentialing issues..members'
Responds to requests received from Aetna’s Law Document Center regarding litigation; lawsuits Handles extensive file review requests. Assists in the preparation of complaint trend report.
Assists in compiling claim data reports for customer audits. Determines medical necessity, applicable coverage provisions and verifies member plan eligibility relating to incoming correspondence and internal referrals. Handles incoming requests for appeals and pre-authorizations not handled by Clinical Claim Management.
Performs review of member claim history to ensure accurate tracking of benefit maximums and/or coinsurance/deductible. Performs financial data maintenance as necessary. Uses applicable system tools and resources to produce quality letters and spreadsheets in response to inquiries received.
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