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Customer Service Representative

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Location: San Antonio TX

Company Name: Aetna

Occupational Category: 43-4051.00,Customer Service Representatives

Date Posted: 2020-02-12

Valid Through: 2020-03-13

Employment Type: FULL_TIME


Req ID: 67553BR

Job Description

Customer Service Representative is the face of Aetna and impacts member and provider service experience by manner of how customer service inquiries and problems via telephone, internet or written correspondence are handled. Customer inquiries are of complex nature. Engages, consults and educates providers based upon the member s unique Aetna plans, tools and resources to help guide the member along a clear path to care.

Fundamental Components included but are not limited to:
• Answers questions and resolves issues based on phone calls/letters from providers and plan sponsors.
• Triages resulting rework to appropriate staff.
• Documents and tracks contacts with members, providers and plan sponsors.
• The CSR guides the provider through the member's plan of benefits, Aetna policy and procedures as well as having knowledge of resources to comply with any regulatory guidelines.
• Creates an emotional connection with our providers by understanding and engaging the provider to the fullest to champion for our members' best health.
• Taking accountability to fully understand the provider s needs by building a trusting and caring relationship with the provider.
• Anticipates customer needs.
• Provides the customer with related information to answer the unasked questions, e.g. additional plan details, benefit plan details, provider self-service tools, etc.
• Uses customer service threshold framework to make financial decisions to resolve provider issues.
• Explains provider'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/ASD 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 provider 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:
• Customer Service experiences in a transaction based environment such as a call center or retail location preferred, demonstrating ability to be empathetic, helpful, professional and compassionate.
• Experience in a production environment. High School or GED equivalent.
• Candidate will need to be extremely computer savvy, as the position will require the use of over 10 different systems, multiple monitors and a fast-paced environment.

Functional Skills:

Customer Service - Customer service - Medical billing, Customer Service - Customer service - transaction based environment, Customer Service - FE Customer Service - Provider - Traditional, General Management - Data analysis & interpretation, General Management - Process & quality improvement

Technology Experience:

Desktop Tool - Microsoft Word, Desktop Tool - TE Microsoft Excel, Subject Discipline - Customer Relationship Management

Required Skills:

General Business - Applying Reasoned Judgment, General Business - Communicating for Impact, General Business - Maximizing Work Practices, General Business - Turning Data into Information, Leadership - Anticipating and Innovating, Leadership - Driving a Culture of Compliance, Sales - Delivering on the Promise, Service - Creating a Differentiated Service Experience, Service - Handling Service Challenges, Service - Working Across Boundaries

Desired Skills:

Benefits Management - Interacting with Medical Professionals, General Business - Applying Reasoned Judgment, General Business - Communicating for Impact, General Business - Demonstrating Business and Industry Acumen

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.

Benefit Eligibility

Benefit eligibility may vary by 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