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Aetna is now a CVS Health Company

Medical Review Administrator

Primary Location: Franklin, TN
Additional Locations: TN-Franklin
Medical Review 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, members and providers. Activities may include providing claim status information, benefit coverage interpretations, and explaining medical review process. 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 sound decisions to resolve member issues. Processes medical review record requests and follow-up. Escalates issues as appropriate through the target system for grievances and appeals. Through in-depth analysis, identifies complaint trends and any emerging customer service issues and works to develop solutions to address potential problems. Partners with other departments to deliver client resolution of medical review requests. 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,relative to medical claims review. Coaches, trains and assists in the development of call center staff. May participate and/or lead special projects/initiatives addressing service issues. 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 in a production environment. Demonstrated ability to handle multiple assignments competently, accurately and efficiently. Medical record review, coding and administration is considered a plus. 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. Analytical skills.

Required Skills:
General Business - Applying Reasoned Judgment, General Business - Communicating for Impact, Service - Handling Service Challenges

Desired Skills:
Benefits Management - Interacting with Medical Professionals, General Business - Demonstrating Business and Industry Acumen, Service - Providing Solutions to Constituent Needs

Functional Skills:
Administration / Operation - Data Entry, Administration / Operation - File Maintenance, Administration / Operation - Telephone / Receptionist, Customer Service - Customer service - transaction based environment, Medical Management - Medical Management - Managed Care/Insurance Administration

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

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)


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