Description: The Customer Service Representative will handle Provider customer service inquiries and problems via telephone, internet or written correspondence. Customer inquiries are of basic and routine nature.
Fundamental Components: - 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. Background Experience: - 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. Additional Job Information: Experience in a production environment. Customer Service experience in a transaction based environment such as a call center or retail location preferred. 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. Required Skills: Leadership - Driving Change, Service - Working Across Boundaries Desired Skills: Service - Creating a Differentiated Service Experience, Service - Handling Service Challenges, Service - Providing Solutions to Constituent Needs Potential Telework Position: No Percent of Travel Required: 0 - 10% EEO Statement: Aetna is an Equal Opportunity, Affirmative Action Employer Benefit Eligibility: Benefit eligibility may vary by position. Click here to review the benefits associated with this position. Candidate Privacy Information: Aetna takes our candidate's data privacy seriously. At no time will any Aetna recruiter or employee request any financial or personal information (Social Security Number, Credit card information for direct deposit, etc.) from you via e-mail. Any requests for information will be discussed prior and will be conducted through a secure website provided by the recruiter. Should you be asked for such information, please notify us immediately.