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Aetna is now a CVS Health Company

Member Services Representative

Primary Location: Charleston, WV
Additional Locations: WV-Charleston
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Description:
To increase member satisfaction, retention, and growth by efficiently delivering competitive services to members and providers through a fully-integrated organization staffed by knowledgeable, customer-focused professionals supported by exemplary technologies and processes.

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:
High School or GED equivalent.
Experience in a production environment.
Customer Service experiences in a transaction-based environment such as a call center or retail location preferred.


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.

Are you ready to join a company that is changing the face of health care across the nation? Aetna Better Health of West Virginia is looking for people like you who value excellence, integrity, caring and innovation. As an employee, you’ll join a team dedicated to improving the lives of our members. Our vision incorporates community-based health care that works. We value diversity. Align your career goals with Aetna Better Health of West Virginia, and we will support you all the way.



Required Skills:
Service - Creating a Differentiated Service Experience, Service - Providing Solutions to Constituent Needs, Service - Working Across Boundaries

Desired Skills:
General Business - Maximizing Work Practices, Leadership - Fostering a Global Perspective, Service - Handling Service Challenges

Functional Skills:
Administration / Operation - Data Entry, Administration / Operation - File Maintenance, Communication - Member communications, Customer Service - Customer service - production environment, Customer Service - Customer service - transaction based environment

Technology Experience:
Aetna Application - QNXT, Desktop Tool - Microsoft Outlook, Desktop Tool - Microsoft SharePoint, Desktop Tool - Microsoft Word, Desktop Tool - TE Microsoft Excel

Potential Telework Position:
No

Percent of Travel Required:
0 - 10%

EEO Statement:
Aetna is an Equal Opportunity, Affirmative Action Employer

Benefit Eligibility:
Benefit eligibility may vary by position. Click here to review the benefits associated with this position.

Candidate Privacy Information:
Aetna takes our candidate's data privacy seriously. At no time will any Aetna recruiter or employee request any financial or personal information (Social Security Number, Credit card information for direct deposit, etc.) from you via e-mail. Any requests for information will be discussed prior and will be conducted through a secure website provided by the recruiter. Should you be asked for such information, please notify us immediately.

Click To Review Our Benefits (PDF)

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