Customer Service Representative

• 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
• Guides the member through their members 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
• Uses customer service threshold framework to make financial decisions to resolve member issues
• 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 self-service options
• Assists providers with credentialing and re-credentialing issues
• Responds to requests received from Aetna's Law Document Center regarding litigation
• 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

• 1 year of Customer Service experience
• Experience in a production environment
• Prior experience providing customer service to the senior population, knowledge of medical terminology including Medicare and Medicaid policies
• Must have high speed internet with consistent speeds above 25mbps and adherence to telework agreement

1 year of call center experience

• Affordable medical plan options
• a 401(k) plan (including matching company contributions)
• an employee stock purchase plan
• No-cost programs including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching
• Paid time off
• Flexible work schedules
• Family leave
• Dependent care resources
• Colleague assistance programs
• Tuition assistance
• Retiree medical access