Inbound/Outbound Queue Associate OhioRISE

• Coordinates comprehensive medical services to support quality effectiveness of the organization's health care services
• Handles member calls regarding services and builds, researches, and enters member information into systems
• Communicates with providers to obtain clinical information and enhance the effectiveness of medical management services
• Supports comprehensive coordination of medical services including intake, screening, and referrals to Aetna Better Health
• Performs intake of calls from members or providers regarding services via telephone, fax, EDI
• Utilizes Aetna system to build, research and enter member information
• Screens requests for appropriate referral to medical services staff
• Approve services that do not require a medical review in accordance with the benefit plan
• Performs non-medical research including eligibility verification, COB, and benefits verification
• Maintains accurate and complete documentation of required information that meets risk management, regulatory, and accreditation requirements
• Promotes communication, both internally and externally to enhance effectiveness of medical management services
• Protects the confidentiality of member information and adheres to company policies regarding confidentiality
• Communicate with Aetna Case Managers, when processing transactions for members active in this Program
• Supports the administration of the precertification process in compliance with various laws and regulations and/or NCQA standards
• Places outbound calls to providers to provide information or obtain clinical information for approval of medical authorizations
• Uses Aetna Systems such as MedCompass, QNXT, ProFAX and ProPAT
• Communicates with Aetna Nurses and Medical Directors when processing transactions for members active in this Program

• 1-2 years' experience working as a medical assistant, office assistant or other clinical/equivalent experience
• Call center experience is preferred, 1-2 years
• High School Diploma, GED

Prior authorization experience, 1-2 years

• Affordable medical plan options
• 401(k) plan with matching company contributions
• Employee stock purchase plan
• 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