Customer Service Representative

Description

Discover exciting careers at Aetna. Whether you’re a recent grad or a current student, there could be Aetna jobs and career opportunities for you. Health care is an ever-changing business. But one thing will never change — Aetna’s commitment to bringing value to our customers and putting them at the center of everything we do. Aetna along with President Obama’s Skills for America’s Future initiative has partnered with your college to find top talent. We encourage you to apply today!

Customer Service Representative:

Customer Service Representatives represent the “face” of Aetna, serving as the important first line of contact with our customers. These professionals work directly with our members, doctors and employer groups (companies) to help them better understand our products and services and assist with timely, accurate payment of their claims, while providing a human connection at those times when it is needed most. Employees who are part of our customer service team are talented, dedicated individuals with the skills to make a difference in the lives of our customers.

Summary:

To increase member satisfaction, retention, and growth by efficiently delivering competitive services to members and providers through a fully-integrated organization staffed by knowledgeable, customer-focused professionals supported by exemplary technologies and processes.

Position Summary/Mission:

Handles customer service inquiries and problems via telephone, internet or written correspondence. Customer inquiries are of basic and routine nature.

Fundamental Components & Physical Requirements include but are not limited to:

•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.

Qualifications

Background/Experience Desired:

•Experience in a production environment.

•Customer Service experiences in a transaction based environment such as a call center or retail location preferred.

Background/Experience Required:

•Ability to multi-task to accomplish workload efficiently.

•Analytical skills.

•Ability to maintain accuracy and production standards.

•Technical skills.

•Oral and written communication skills.

•Understanding of medical terminology.

•Problem solving skills.

•Attention to detail and accuracy.

•Negotiation skills.

Education and Certification
Requirements:

High School or GED equivalent.