This position is permanent work from home for any candidate in the EST time zone.
This position also includes a $1000 sign on bonus as well as an additional $2000 90 days post training! (Bonuses are only applicable to specific positions, locations, and business groups. Applicable roles have the bonus language in the job posting.)
• Customer Service Representative is the face of Aetna and impacts members’ service experience by manner of how customer service inquiries and problems via telephone, internet or written correspondence are handled.
• Customer inquiries are of basic and at times complex nature.
• Engages, consults and educates members based upon the member’s unique needs, preferences and understanding of Aetna plans, tools and resources to help guide the members along a clear path to care.
• 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.
• The CSR 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, etc.
• 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 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.
• Customer Service experiences in a transaction based environment such as a call center or retail location preferred, demonstrating ability to be empathetic and compassionate.
• Experience in a production environment.