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 rework to appropriate staff. Documents and tracks contacts with members, providers and plan sponsors. (*) Explains member's rights and responsibilities in accordance with 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 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. (*)
Experience in a production environment.
Customer Service experiences in a transaction based environment such as a call center or retail location preferred, demonstrating ability to be empathetic and compassionate.
The highest level of education desired for candidates in this position is a High School diploma, G.E.D. or equivalent experience.
Functional - Customer Service/Customer Service - Member Services - HMO products/1-3 Years
Technical - Computer Operations/System and Console Operations/1-3 Years/
ADDITIONAL JOB INFORMATION
Aetna is about more than just doing a job. This is our opportunity to re-shape healthcare for America and across the globe. We are developing solutions to improve the quality and affordability of healthcare. What we do will benefit generations to come.
We care about each other, our customers and our communities. We are inspired to make a difference, and we are committed to integrity and excellence.
Together we will empower people to live healthier lives.
Aetna is an equal opportunity & affirmative action employer. All qualified applicants will receive consideration for employment regardless of personal characteristics or status. We take affirmative action to recruit, select and develop women, people of color, veterans and individuals with disabilities.
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. None