POSITION SUMMARYGrowth opportunity in fast paced environment! Handles customer service inquiries and problems via telephone, internet or written correspondence. Customer inquiries are of basic and routine nature.Fundamental Components: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. BACKGROUND/EXPERIENCE desired:Experience in a production environment.Customer Service experiences in a transaction based environment such as a call center or retail location preferred.EDUCATIONThe highest level of education desired for candidates in this position is a High School diploma, G.E.D. or equivalent experience.TECHNOLOGY EXPERIENCESTechnical - Desktop Tools/Microsoft Outlook/4-6 Years/End User
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