Nov 13, 2019

Customer Service Representative

  • Professional Diversity Network
  • Detroit, MI, USA
Full-Time Other

Job Description


Description: 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.

We're looking for people who are passionate about providing exceptional customer service and would like to be part of our member services team that supports the needs and care of our members.


Fundamental Components: Responsibilities include:
  • 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.
  • 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 maintain 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.
  • Ability to multi-task to accomplish workload efficiently.
  • Analytical skills.
  • Ability to maintain accuracy and production standards.
  • Understanding of medical terminology, a plus.
Attention to detail and accuracy Background Experience:
  • Minimum of one year customer service experience.
  • Experience in a production environment, call center preferred.
  • Customer Service experience in a transaction based environment such as a call center, healthcare or retail location.
  • Exceptional communication skills, written and verbal.
  • Demonstrated competencies, problem solving and critical thinking skills.
  • Computer and keyboard navigation skills.
Additional Job Information:
  • Ability to multi-task to accomplish workload efficiently.
  • Understanding of medical terminology.
  • Oral and written communication skills.
  • Ability to maintain accuracy and production standards.
  • Negotiation skills.
  • Technical skills.
  • Problem solving skills.
  • Attention to detail and accuracy.
  • Analytical skills.
Required Skills: Service - Creating a Differentiated Service Experience, Service - Handling Service Challenges, Service - Providing Solutions to Constituent Needs Desired Skills: Benefits Management - Interacting with Medical Professionals, General Business - Maximizing Work Practices, Service - Demonstrating Service Discipline Functional Skills: Communication - Member communications, Customer Service - Customer Service - Member Services - Traditional products, Customer Service - Customer service - production environment, Customer Service - Customer service - transaction based environment Technology Experience: Desktop Tool - Microsoft Outlook, Desktop Tool - Microsoft Word, Desktop Tool - TE Microsoft Excel 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.





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