Aetna Sr Customer Service Rep in Detroit, Michigan

Req ID: 41995BR


Michigan Member Services Sr. Rep handles customer service inquiries and problems via telephone, internet, in person (face to face), or written correspondence. Member inquiries are of basic and of routine nature. Also, this is a lead role where the Sr. Rep will assist the staff with difficult calls/training as well as assist the manager with task specific items.

Fundamental Components:

Were 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. 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 Takes on leadership role with team Have a higher sense of resolve for handling difficult members in a professional and respectful manner to resolve member concern Working on training and staff updates to ensure staff success and comprehension Work with manager on projects as assigned Call Quality Management Provide support to phone queue as required support new hire training Call Center Reporting Review and update call center information resources as required (job aids, desktops, letters, policies/procedures, etc.) Ability to focus on task and see through to completion Understand call center metrics/requirements Understanding of NCQA requirements Understand CMS/Medicare/Medicaid Ability to be very flexible other duties as assigned


Experience in a production environment.

Customer Service experience in a transaction based environment.

Demonstrated ability to handle multiple assignments competently, accurately, timely, and efficiently.

Demonstrated ability to de-escalate members and effectively resolve member complaints/concerns prefessionally

Demonstrated problem solver Demonstrated ability to coach/train staff


The highest level of education desired for candidates in this position is a Associate's degree or equivalent experience.


Functional - Customer Service/Customer Service - Member Services - Traditional products/1-3 Years

Functional - Customer Service/Customer service - production environment/1-3 Years

Functional - Communications/Member communications/1-3 Years

Functional - Customer Service/Customer Service - Call Quality Audit - Inbound call monitoring/1-3 Years

Functional - Customer Service/Customer service - transaction based environment/1-3 Years


Technical - Call Management/ACD (Automatic Call Distribution)/1-3 Years/End User

Technical - Desktop Tools/Microsoft Word/1-3 Years/End User

Technical - Desktop Tools/Microsoft Outlook/1-3 Years/End User

Technical - Desktop Tools/TE Microsoft Excel/1-3 Years/End User


Service/Handling Service Challenges/ADVANCED

Service/Providing Solutions to Constituent Needs/ADVANCED

Service/Creating a Differentiated Service Experience/ADVANCED


General Business/Communicating for Impact/FOUNDATION

Leadership/Engaging and Developing People/FOUNDATION

Service/Demonstrating Service Discipline/ADVANCED


This role will allow the candidate to showcase their skills in problem solving, leadership, and customer service. This role will need a candidate who is extremely, thorough, highly detail oriented, able to handle confidential and sensitive information, and promote teambuilding.

Aetna is about more than just doing a job. This is our opportunity to re-shape healthcare for America and across the globe. We are developing solutions to improve the quality and affordability of healthcare. What we do will benefit generations to come.

We care about each other, our customers and our communities. We are inspired to make a difference, and we are committed to integrity and excellence.

Together we will empower people to live healthier lives.

Aetna is an equal opportunity & affirmative action employer. All qualified applicants will receive consideration for employment regardless of personal characteristics or status. We take affirmative action to recruit, select and develop women, people of color, veterans and individuals with disabilities.

We are a company built on excellence. We have a culture that values growth, achievement and diversity and a workplace where your voice can be heard.

Benefit eligibility may vary by position. Click here to review the benefits associated with this position.

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.

Job Function: Customer Service