Member Service RepresentativePrimary Location: Linthicum, MD
Additional Locations: MD-Linthicum Apply
- 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 having knowledge of 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 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.
- 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. High School or GED equivalent.
- 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.
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