Customer Service Representative

Position Summary

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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.

Customer inquiries are of a basic and at times complex nature.

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.

We are a 24/7 customer service inbound call operation. Our calls are 24 x 7, 365 days a year which includes weekends and holidays.

Being able to work any shift which includes overnights weekends and holidays is a requirement for this position. We are looking for candidates who can work ANY shift based on business needs.

  • 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.
  • The CSR guides the member through their members plan of benefits, Aetna policy and procedures as well as knowing resources to comply with any regulatory guidelines.
  • Creates an emotional connection with our members by understanding and engaging the member to the fullest to champion for our members’ best health.
  • Taking accountability to fully understand the member’s needs by building a trusting and caring relationship with the member.
  • Anticipates customer needs. Provides the customer with related information to answer the unasked questions, e.g. additional plan details, benefit plan details, member self-service tools, etc.
  • Uses customer service threshold framework to make financial decisions to resolve member issues.
  • Explains member’s rights and responsibilities under 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.
  • Review member claim history to ensure accurate tracking of benefit maximums and/or coinsurance/deductibles.
  • Review member claim history to ensure accurate tracking of benefit maximums and/or coinsurance/deductibles.
  • Performs financial data maintenance as necessary.
  • Uses applicable system tools and resources to produce quality letters and spreadsheets in response to inquiries received.


Preferred Qualifications

Customer Service experiences in a transaction-based environment such as a call center or retail location preferred, demonstrating the ability to be empathetic and compassionate.

Experience in a production environment.

  • Ability to multi-task to accomplish workload efficiently.
  • Understanding of medical terminology.
  • Proficient oral and written communication skills.
  • Proficient with Microsoft Word and Outlook.
  • Ability to maintain accuracy and production standards.
  • Negotiation skills.
  • Technical skills.
  • Problem-solving skills.
  • Attention to detail and accuracy.
  • Analytical skills

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