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

Inbound/Outbound Queue Associa

Primary Location: San Diego, California
Additional Locations: CA-San Diego
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POSITION SUMMARY
Supports comprehensive coordination of medical services including intake, screening and referrals to Aetna Medical Services Programs. Promotes/supports quality effectiveness of Healthcare Services.

Fundamental Components:

  • Performs intake of calls from members or providers regarding services via telephone, fax
  • Utilizes Aetna system to build, research and enter member information.
  • Screens requests for appropriate referral to medical services staff.
  • Approve services that do not require a medical review in accordance with the benefit plan.
  • Performs non-medical research including eligibility verification, COB, and benefits verification.
  • Maintains accurate and complete documentation of required information that meets risk management, regulatory, and accreditation requirements.
  • Promotes communication, both internally and externally to enhance effectiveness of medical management services (e.g., claim administrators, Plan Sponsors, and third party payers as well as member, family, and health care team members respectively)
  • Protects the confidentiality of member information and adheres to company policies regarding confidentiality (*)
  • Communicate with Aetna team members, Nurses and Medical Director, when processing transactions for members (*)
  • Supports the administration of the precertification process in compliance with various laws and regulations, URAQ and/or NCQA standards, where applicable, while adhering to company policy and procedures. (*)
  • Places outbound calls to providers under the direction of Medical Management Nurses to obtain clinical information for approval of medical authorizations.
  • Uses Aetna Systems such as QNXT, ProFAX, and ProPAT
  • Sedentary work involving significant periods of sitting, talking, hearing and keying. Work requires visual acuity to perform close inspection of written and computer generated documents as well as a PC monitor. Working environment includes typical office conditions.
Additional Information (situational competencies, skills, work location requirements, etc.)
Strong customer service skills to coordinate service delivery including attention to customers, sensitivity to issues, proactive identification and resolution of issues to promote positive outcomes for members.
Computer literacy in order to navigate through internal/external computer systems, including Excel and Microsoft Word.
Ability to effectively participate in an interprofessional team including internal and external participants.
Familiarity with basic medical terminology and concept

BACKGROUND/EXPERIENCE desired:
2-4 years experience as a medical assistant, office assistant or other clinical experience.

EDUCATION

The highest level of education desired for candidates in this position is a High School diploma, G.E.D. or equivalent experience.

FUNCTIONAL EXPERIENCES

Functional - Communications//1-3 Years
Functional - Customer Service//1-3 Years
Functional - Administration / Operations/Data Entry/1-3 Years
Functional - Administration / Operations/Mail Processing/1-3 Years
Functional - Administration / Operations/Telephone / Receptionist/1-3 Years


REQUIRED SKILLS
Service/Demonstrating Service Discipline/FOUNDATION
Service/Handling Service Challenges/FOUNDATION
Service/Providing Solutions to Constituent Needs/FOUNDATION


ADDITIONAL JOB INFORMATION
Department staff are team players and work together as a team and achieve all department goals. Friendly work environment.

Come join an exciting new Health Plan that serves our most vulnerable population! We are a growing team and health plan. Aetna Better Health of California is about more than just doing a job. This is our opportunity to re-shape healthcare for our population.

We care about each other, our customers and our communities. We are inspired to make a difference, and we are committed to integrity and excellence.Together we will empower people to live healthier lives.

We are a company built on excellence. We have a culture that values growth, achievement and diversity and a workplace where your voice can be heard.

Aetna is about more than just doing a job. This is our opportunity to re-shape healthcare for America and across the globe. We are developing solutions to improve the quality and affordability of healthcare. What we do will benefit generations to come.

We care about each other, our customers and our communities. We are inspired to make a difference, and we are committed to integrity and excellence.

Together we will empower people to live healthier lives.

Aetna is an equal opportunity & affirmative action employer. All qualified applicants will receive consideration for employment regardless of personal characteristics or status. We take affirmative action to recruit, select and develop women, people of color, veterans and individuals with disabilities.

We are a company built on excellence. We have a culture that values growth, achievement and diversity and a workplace where your voice can be heard.





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



Aetna takes our candidates'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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