Accountable For Increasing Member And Provider Satisfaction, Retention, And Growth By Effectively Providing Competitive Service To Members And Providers Through A Fully Integrated Organization With Professional Customer Focused Support Through Ideal Technologies And Processes. The Customer Service Representative Is The Face Of Aetna And Influences The Member Experience Through The Way Customer Service Questions And Issues Are Handled Over The Phone, The Internet, Or Written Correspondence.

• Customer Questions Are Basic And Sometimes Complex.
• Engages, Consults, And Educates Members Based On Their Unique Needs, Preferences, And Understanding Of Aetna Plans, Tools, And Resources To Help Members Navigate A Clear Path To Care.
• Answers Questions And Resolves Issues Based On Phone Calls/Letters From Members, Providers And Plan Sponsors.
• Efforts That Lead To The Re-Employment Of Suitable Personnel. Documents And Tracks Contact With Members, Providers, And Plan Sponsors. The CSR Guides The Member Through The Member Benefits Plan, and Aetna Policies And Procedures, And Is Also Knowledgeable About The Means To Meet All Regulatory Guidelines.
• Creates An Emotional Connection With Our Members By Fully Understanding And Engaging The members in The Fight For Our Members' Best Health.
• Take Responsibility For Fully Understanding Member Needs By Building A Trusting And Caring Relationship With The Member. Anticipate Customer Needs.
• Provides Relevant Information To The Customer, For Example, To Answer Unasked Questions.
• Additional Plan Details, Benefit Plan Details, Member Self-Service Tools And More.
• Uses A Customer Service Framework To Make Financial Decisions To Solve Member Problems.
• It Explains The Member's Rights And Obligations Under The Contract.
• Request Referrals, New Request Transfers, Nurse Ratings, Grievances (Member/Provider), Grievances And Appeals (Member/Provider) Through A Streamlined System.
• Educates Providers About Our Self-Service Options; Assists Providers With Qualifications And Credentials.
• Responds To Requests Received From Aetna's Law Document Center Regarding Litigation; Court Cases.
• Handles Multiple File Check Requests. Assists In The Preparation Of Complaint Trend Reports.
• Assists In Compiling Claims Data For Customer Audits.
• Determine Medical Necessity and applicable Coverage Provisions, And Verify Member Plan Eligibility In Connection With Incoming Correspondence And Internal Referrals.
• Processes Incoming Appeals And Prior Authorization Requests Not Processed By Clinical Claim Management.
• Conducts Review Of Member Claim History To Ensure Accurate Adherence To Maximum Benefits And/Or Coinsurance/Deductibles.
• Performs Financial Data Maintenance As Needed.
• Utilizes Available System Tools And Resources To Produce Quality Letters And Tables In Response To Inquiries Received.
• Strong Technical Knowledge Of The Function Being Trained.

Required Qualifications

• Customer Service Experience In A Transaction-Based Environment Such As A Call Center.
• Experience In A Manufacturing Environment.

Preferred Qualifications

• Medicaid Or Healthcare Experience.

Job Benefits:

• Health Benefits: Because Aetna Is A Health Insurance Company, It Generally Offers Comprehensive Health Benefits, Including Health, Dental, And Vision Insurance, To Eligible Employees And Dependents.
• Wellness Programs: Aetna Promotes Employee Wellness Through A Variety Of Programs, Which May Include Exercise Groups, Health Challenges, And Resources To Maintain A Healthy Lifestyle.
• 401(K) Retirement Plan: Aetna May Offer A 401(K) Plan That Allows Employees To Save For Retirement Through Tax-Deductible Contributions. Some Companies Also Offer Matching Offers.
• Time Off (PTO): This Can Include Vacation Days, Sick Days, And Statutory Holidays, Allowing Employees To Take Time Off Work While Still Being Paid.
• Flexible Spending Accounts (FSA): These Accounts Allow Employees To Withdraw Pre-Tax Dollars To Cover Medical, Dental And Dependent Care Expenses.
• Life Insurance And Disability Insurance: Aetna Can Provide Life Insurance And Disability Insurance To Help Protect Employees And Their Families Financially.
• Employee Assistance Programs (Eaps): Eaps Provide Support For Personal And Employment Issues, Including Counseling, Legal Assistance, And Financial Planning.
• Professional Development: Aetna Can Provide Professional Development Opportunities Through Training, Courses, And Educational Resources.
• Parental Leave: Maternity And Paternity Leave To Support Employees When They Become Parents.
• Tuition Assistance: Some Companies, Including Aetna, Offer Tuition Reimbursement Or Assistance Programs To Help Employees Continue Their Education.
• Employee Discounts: Discounts On Aetna Health Insurance Plans And Other Potential Products And Services.
• Remote And Flexible Work: Depending On The Service, Aetna May Offer Flexible Work Arrangements Or Remote Work Options.