Aetna Member Services Representative in Charleston, West Virginia
Req ID: 64878BR
Aetna Better Health of WV (ABHWV) is honored to join the WV Department of Health and Human Services (DHHR) in its mission to keep children safe at home. ABHWV will welcome you to a dynamic team of mission driven individuals who believe that foster children deserve better. At the end of the day, this is about giving children a chance to thrive and supporting all families in our community.
To increase member satisfaction, retention, and growth by efficiently delivering competitive services to members and providers through a fully-integrated organization staffed by knowledgeable, customer-focused professionals supported by exemplary technologies and processes.
Handles customer service inquiries and problems via telephone, internet or written correspondence. Customer inquiries are of basic and routine nature.
Fundamental Components included but are not limited to:
• 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.
• 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
Qualifications Requirements and Preferences:
• High School or GED equivalent.
• Experience in a production environment.
• Customer Service experiences in a transaction-based environment such as a call center or retail location preferred.
Administration / Operation - Data Entry, Administration / Operation - File Maintenance, Communication - Member communications, Customer Service - Customer service - production environment, Customer Service - Customer service - transaction based environment
Aetna Application - QNXT, Desktop Tool - Microsoft Outlook, Desktop Tool - Microsoft SharePoint, Desktop Tool - Microsoft Word, Desktop Tool - TE Microsoft Excel
Service - Creating a Differentiated Service Experience, Service - Providing Solutions to Constituent Needs, Service - Working Across Boundaries
General Business - Maximizing Work Practices, Leadership - Fostering a Global Perspective, Service - Handling Service Challenges
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.
Are you ready to join a company that is changing the face of health care across the nation? Aetna Better Health of West Virginia is looking for people like you who value excellence, integrity, caring and innovation. As an employee, you ll join a team dedicated to improving the lives of our members. Our vision incorporates community-based health care that works. We value diversity. Align your career goals with Aetna Better Health of West Virginia, and we will support you all the way.
Benefit eligibility may vary by position. Click here to review the benefits associated with this position.
Job Function: Customer Service
Aetna is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected Veterans status.