Aetna is expanding our Engagement Hub services. The Engagement Hubs are focused on driving member engagement into Aetna’s Care Management programs, while also delivering care services to members who do not need long-term support but have immediate care needs. Columbia, SC, Jacksonville, FL, Monroeville, PA, Harrisburg, PA, are Also Fully remote.
The Engagement Specialist is responsible for telephonic outreach to and enrollment of our eligible members. Our Engagement Specialists demonstrate a highly energetic blend of salesperson, health care navigator, and health plan customer support representative. The Engagement Specialist is responsible for direct member outreach and engagement, facilitating case assignments, and connecting identified members to care managers immediately through a warm transfer. Read employee reviews here
Jacksonville, FL
Job Responsibilities:
Initiates telephonic engagement with assigned members to introduce the program with the goal of enrolling the member in Aetna Care Management.
Effectively meets daily metrics with speed, accuracy, and a positive attitude. The metrics are focused on unique members attempted daily and the volume of members that agree to enroll in care management. This is not a sales position, enrollment is free, but influencing is important to this work.
Documentation is critical to success. The Engagement Specialist accurately and consistently document each call in the member's electronic record, thoroughly completing required actions with a high level of detail to ensure we meet our compliance requirements
Effectively supports members during enrollment calls, appropriately managing difficult or emotional member situations, responding promptly to member needs, and demonstrating empathy and a sense of urgency when appropriate
Conducts triage, connecting members with appropriate care team personnel including care managers and customer service
Demonstrates an outgoing, enthusiastic, and caring presence over the telephone.
Works efficiently and independently, meeting deliverables and deadlines
Adheres to care management, privacy and confidentiality, and quality management processes in compliance with regulatory, accreditation guidelines, company policies, and procedures
Demonstrates an ability to be agile, managing multiple priorities at one time, and adapting to change with enthusiasm
Other responsibilities as assigned
Required Qualifications
Experience with computers including knowledge of Microsoft Word, Outlook, and Excel – data entry and documentation within member records is preferred
2 years of experience preferably in customer service, telemarketing, and/or sales
Call center experience preferred Familiarity with basic medical terminology preferred
Flexibility to work occasional nights and weekends outside of standard business hours which can span from 8:00 am 8:00 pm
Strong organizational skills, including effective verbal and written communications skills
Bilingual (Spanish) preferred
Job Description PA
The supervisor is responsible for providing operational leadership and direction for Prior Authorization and Appeals business units.
The position has a primary focus on ensuring compliance with all state regulations. Other key areas of focus include quality improvement, innovation, and reduction of unit costs. Responsibilities of the position include daily operational oversight, staff development, budget management, audit readiness, staff training documentation and execution and policy, and procedure documentation.
The leader will work with internal partners and the PA staff to ensure the ability to service physicians, pharmacists, and patients within service levels and provide appropriate clinical drug therapies. Essential Functions of the job include: Lead the PA and Appeals operational unit including ensuring regulatory compliance with state regs regarding the processing of prior authorizations and appeals. Ensure standardization and consistency in practices, procedures, and workflow to improve efficiency and quality.
Required Qualifications
3+ years of relevant work experience required that includes prior experience in Clinical Services Operations; Prior Authorization and/or Appeals experience; or PBM/Pharmacy Operations.
Demonstrated experience managing staff. Demonstrated ability to work in a fast pace, multi-tasking team environment while meeting deadlines.
Coordinate with IROs and IRE external organizations to ensure business requirements are met. Develop an annual business plan for the department to include revenue and expense forecasts, resource justifications, and performance
analysis of the department. Understand and ensure end-to-end regulatory compliance with all state, federal, and other regulatory and client requirements.
Columbia, SC
The Engagement Specialist is responsible for telephonic outreach to and enrollment of our eligible members. Our Engagement Specialists demonstrate a highly energetic blend of salesperson, health care navigator, and health plan customer support representative.
The Engagement Specialist is responsible for direct member outreach and engagement, facilitating case assignments, and connecting identified members to care managers immediately through a warm transfer. Job Responsibilities: Initiates telephonic engagement with assigned members to introduce the program with the goal of enrolling the member in Aetna Care Management. Effectively meets daily metrics with speed, accuracy, and a positive attitude. The metrics are focused on unique members attempted daily and the volume of members that agree to enroll in care management. This is not a sales position, enrollment is free, but influencing is important to this work. Documentation is critical to success. The Engagement Specialist accurately and consistently document each call in the member's electronic record, thoroughly completing required actions with a high level of detail to ensure we meet our compliance requirements Effectively supports members during enrollment calls, appropriately managing difficult or emotional member situations, responding promptly to member needs, and demonstrating empathy and a sense of urgency when appropriate Conducts triage, connecting members with appropriate care team personnel including care managers and customer service Demonstrates an outgoing, enthusiastic, and caring presence over the telephone. Works efficiently and independently, meeting deliverables and deadlines Adheres to care management, privacy and confidentiality, and quality management processes in compliance with regulatory, accreditation guidelines, company policies and procedures Demonstrates an ability to be agile, managing multiple priorities at one time, and adapting to change with enthusiasm Other responsibilities as assigned
Required Qualifications Experience with computers including knowledge of Microsoft Word, Outlook, and Excel – data entry and documentation within member records is preferred 2 years of experience preferably in customer service, telemarketing, and/or sales Call center experience preferred Familiarity with basic medical terminology preferred Flexibility to work occasional nights and weekends outside of standard business hours which can span from 8:00 am 8:00 pm Strong organizational skills, including effective verbal and written communications skills Bilingual (Spanish) preferred
COVID Requirements
– Call Center, Monroeville, PA
Our Engagement Specialists demonstrate a highly energetic blend of salesperson, health care navigator, and health plan customer support representative. The Engagement Specialist is responsible for direct member outreach and engagement, facilitating case assignments, and connecting identified members to care managers immediately through a warm transfer. Job Responsibilities: Initiates telephonic engagement with assigned members to introduce the program with the goal of enrolling the member in Aetna Care Management. Effectively meets daily metrics with speed, accuracy, and a positive attitude. The metrics are focused on unique members attempted daily and the volume of members that agree to enroll in care management. This is not a sales position, enrollment is free, but influencing is important to this work. Documentation is critical to success. The Engagement Specialist accurately and consistently document each call in the member's electronic record, thoroughly completing required actions with a high level of detail to ensure we meet our compliance requirements Effectively supports members during enrollment calls, appropriately managing difficult or emotional member situations, responding promptly to member needs, and demonstrating empathy and a sense of urgency when appropriate Conducts triage, connecting members with appropriate care team personnel including care managers and customer service Demonstrates an outgoing, enthusiastic, and caring presence over the telephone. Works efficiently and independently, meeting deliverables and deadlines Adheres to care management, privacy and confidentiality, and quality management processes in compliance with regulatory, accreditation guidelines, company policies, and procedures Demonstrates an ability to be agile, managing multiple priorities at one time, and adapting to change with enthusiasm Other responsibilities as assigned
Required Qualifications Experience with computers including knowledge of Microsoft Word, Outlook, and Excel – data entry and documentation within member records is preferred 2 years of experience preferably in customer service, telemarketing, and/or sales Call center experience preferred Familiarity with basic medical terminology preferred Flexibility to work occasional nights and weekends outside of standard business hours which can span from 8:00 am 8:00 pm Strong organizational skills, including effective verbal and written communications skills Bilingual (Spanish) preferred
Engagement Specialist – Work from Home – Call Center Harrisburg, PA, Bilingual (Spanish) preferred
Job Responsibilities: Initiates telephonic engagement with assigned members to introduce the program with the goal of enrolling the member in Aetna Care Management. Effectively meets daily metrics with speed, accuracy, and a positive attitude. The metrics are focused on unique members attempted daily and the volume of members that agree to enroll in care management. This is not a sales position, enrollment is free, but influencing is important to this work. Documentation is critical to success. The Engagement Specialist accurately and consistently document each call in the member's electronic record, thoroughly completing required actions with a high level of detail to ensure we meet our compliance requirements Effectively supports members during enrollment calls, appropriately managing difficult or emotional member situations, responding promptly to member needs, and demonstrating empathy and a sense of urgency when appropriate Conducts triage, connecting members with appropriate care team personnel including care managers and customer service Demonstrates an outgoing, enthusiastic, and caring presence over the telephone. Works efficiently and independently, meeting deliverables and deadlines Adheres to care management, privacy and confidentiality, and quality management processes in compliance with regulatory, accreditation guidelines, company policies and procedures Demonstrates an ability to be agile, managing multiple priorities at one time, and adapting to change with enthusiasm Other responsibilities as assigned
Required Qualifications Experience with computers including knowledge of Microsoft Word, Outlook, and Excel – data entry and documentation within member records is preferred 2 years of experience preferably in customer service, telemarketing and/or sales Call center experience preferred Familiarity with basic medical terminology preferred Flexibility to work occasional nights and weekends outside of standard business hours which can span from 8:00 am 8:00 pm Strong organizational skills, including effective verbal and written communications skills Bilingual (Spanish) preferred
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 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. -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 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.
Required Qualifications -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. -Experience in a production environment.
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