Skip to main content

A new day in healthcare. Together, CVS Health and Aetna help people on their path to better health.

Senior Custormer Service Representative

Primary Location: Dallas, TX
Additional Locations: TX-Dallas
  • 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.
  • Calls are typically non-routine and may require deviation from standard screens, scripts and procedures to engage, consult and educate 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.
  • Act as subject matter expert by providing training, coaching, or responding to complex issues. May analyze and adjudicate claims.

Fundamental Components:
  • Answers questions and resolves issues as a "single-point-of-contact" based on phone calls, letters, and internet from brokers, marketing plan sponsors, PSS/ISO, members and providers. Activities may include providing claim status information, benefit coverage interpretations, and explaining plan eligibility.
  • 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.
  • Processes claim referrals, new claim hand-offs, nurse reviews, and member/provider complaints. Escalates issues as appropriate through the target system for grievances and appeals.
  • Initiates out-reach/welcome calls to ensure constituents expectations are met or exceeded. Through in-depth analysis, identifies complaint trends and any emerging customer service issues and works to develop solutions to address potential problems.
  • Educates customers on various elements of benefit plan information and available services created to enhance the overall customer service experience with the company (i.e., assistance with member self-service tools).
  • Partners with other departments to deliver client specific presentations. Coordinates efforts both internally and across departments to successfully resolve service issues and develop process improvements intended to enhance the overall delivery of service.
  • Serves as SME providing technical assistance when needed on call related issues, products, and/or system applications delivery matters.
  • Coaches, trains and assists in the development of call center staff. May participate and/or lead special projects/initiatives addressing service issues.
  • May provide technical or subject matter expertise concerning policies, procedures, and function-related applications/systems tools.
  • Delivers internal quality reviews. Provides appropriate support in third party audits when required.
  • Documents and tracks all contacts, events, and outcomes with clients using appropriate systems and processes

Background Experience:
  • Customer Service experiences in a transaction based environment such as a call center or retail location preferred, demonstrating ability to be empathetic and compassionate.
  • Experience with Medicaid/Medicare and/or health insurance preferred but not required.
  • Experience in a production environment. Demonstrated ability to handle multiple assignments competently, accurately and efficiently.
  • Experience in a high volume call center
  • Customer Service Call Center environment a plus. Bilingual preferred, but not required.
  • Associate's degree or equivalent work experience

Additional Job Information:
  • Understanding of medical terminology.
  • Strong knowledge of benefit plans, policies and procedures.
  • Oral and written communication skills.
  • Ability to maintain accuracy and production standards.
  • Negotiation skills.
  • Technical skills.
  • Problem solving skills.
  • Attention to detail and accuracy.
  • Effective time management and organizational skills
  • Self- starter

Required Skills:
General Business - Applying Reasoned Judgment, Leadership - Collaborating for Results, Service - Handling Service Challenges, Service - Providing Solutions to Constituent Needs

Desired Skills:
Leadership - Anticipating and Innovating, Leadership - Creating Accountability, Leadership - Engaging and Developing People, Service - Working Across Boundaries

Functional Skills:
Customer Service - Call center monitoring & analysis - Inbound calls - call center location, Customer Service - Customer Service - Dental, Customer Service - Customer Service - Member Services - HMO products, Customer Service - Customer Service - Pharmacy, Customer Service - FE Complaints, grievances & appeals

Potential Telework Position:

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)


Jobs for you

Recently Viewed Jobs

You do not have any recently viewed jobs

Your Saved Jobs

You do not have any saved jobs

Sign up for Job Alerts

Join our Talent Community

At Aetna, we are pioneering a total approach to health and wellness and we need talented candidates like you to join our team. Become a member of our talent community to be the first to know about career initiatives that match your skills and interests as they become available, in addition to details on upcoming events, networking opportunities, and news about Aetna.

Join Our Talent Community

Sign up to receive information about job openings that are tailored to your skills and interests. Plus, get the latest career news from Aetna.