![]() Experience in a production environment.Customer Service experiences in a transaction-based environment such as a call center or retail location preferred, demonstrating ability to be empathetic and compassionate.Uses applicable system tools and resources to produce quality letters and spreadsheets in response to inquiries received. Performs financial data maintenance as necessary.Performs review of member claim history to ensure accurate tracking of benefit maximums and/or coinsurance/deductible. Handles incoming requests for appeals and pre-authorizations not handled by Clinical Claim Management.Determines medical necessity, applicable coverage provisions and verifies member plan eligibility relating to incoming correspondence and internal referrals.Assists in compiling claim data for customer audits.Assists in preparation of complaint trend reports.Handles extensive file review requests.Responds to requests received from Aetna's Law Document Center regarding litigation lawsuits.Educates providers on our self-service options Assists providers with credentialing and re-credentialing issues.Processes claim referrals, new claim handoffs, nurse reviews, complaints (member/provider), grievance and appeals (member/provider) via target system.Explains member's rights and responsibilities in accordance with contract.Uses customer service threshold framework to make financial decisions to resolve member issues.additional plan details, benefit plan details, member self-service tools, etc. Provides the customer with related information to answer the unasked questions, e.g.Taking accountability to fully understand the member’s needs by building a trusting and caring relationship with the member.Creates an emotional connection with our members by understanding and engaging the member to the fullest to champion for our members' best health.The CSR guides the member through their members plan of benefits, Aetna policy and procedures as well as having knowledge of resources to comply with any regulatory guidelines. ![]() Documents and tracks contacts with members, providers and plan sponsors.Triages resulting rework to appropriate staff.Answers questions and resolves issues based on phone calls/letters from members, providers, and plan sponsors.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.Customer inquiries are of basic and at times complex nature.The 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.This position is permanent work from home for candidates in the east and west coast time zone.
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