Aetna Customer Svc Consultant in Shanghai, China

Req ID: 50861BR

Family Summary/Mission:

Achieve superior claim and member service performance through an integrated process of operational, quality, medical cost, and resource management meeting and/or exceeding member, plan sponsor, and provider expectations.

Position Summary/Mission:

Provide operational and logistical support to Clinical Case Managers, working in partnership to coordinate the delivery of pre-authorisation services. Rapidly investigate, review and adjudicate claims in advance of treatment taking place.

Fundamental Components & Physical Requirements:

  • Working within the Member Assistance contact center, investigate, consider and pre-authorise treatment globally.

  • Professionally manage inbound and outbound telephone, fax and email correspondence with customers, brokers, suppliers and all other interested parties ensuring that appropriate and timely communication is maintained at all times.

  • Complete eligibility verification, escalate medical information to Clinical Case Managers, determine coverage, identify discrepancies, and apply all cost containment measures including identification of opportunities for subrogation and recovery.

  • Triage and prioritise caseload considering urgency, geographical location and service level.

  • Take ownership for progression of own caseload, maintain communication, remove barriers, avoid delays.

  • Follow appropriate escalation process for high dollar claims.

  • Investigate claims for possible abuse and fraud.

  • May facilitate training and coaching when considered topic subject matter expert.

  • Escalate unresolved claims complaints and high costs claims to Service Delivery Leader for guidance.

  • Continually work to improve best practices procedures and standards.

  • Ensure compliance with requirements of regional compliance authority/industry regulator.

  • Adheres to international privacy policies, practices and procedures.

  • Strives to deliver consistently excellent customer service internally and externally.

Background/Experience Desired:

  • Previous experience in a Clinical or Medical Assistance Environment highly desirable

  • Proven telephone customer service experience

  • Highly beneficial to have worked in an insurance environment

Educational Requirements:

· Clinical qualification would be high beneficial but not essential

· Fluent in English and highly desirable to have Arabic language skills

Additional Information (not mandatory to complete):

  • Working knowledge of Word, Excel, Email and Internet.

  • Competent typist

  • Excellent customer service skills with a strong command of written and spoken English.

  • Good communicator with strong organisational and problem solving skills.

  • This role will have different work patterns to the normal Aetna Dubai contracts. The work patterns are being finalized.

Job Function: Customer Service