Aetna Customer Service Representative in Detroit, Michigan

Req ID: 54143BR


Were looking for people who are passionate about providing exceptional customer service and would like to be part of our member services team that supports the needs and care of our members.

Fundamental Components

Responsibilities include:

  • Answers questions and resolves issues based on phone calls/letters from members, providers, and plan sponsors.

  • Triage 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 hand offs, 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.

  • 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 maintain 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.

  • Ability to multi-task to accomplish workload efficiently. Analytical skills. Ability to maintain accuracy and production standards.

  • Understanding of medical terminology, a plus.

  • Attention to detail and accuracy.


Minimum of one year customer service experience. Experience in a production environment, call center preferred. Customer Service experience in a transaction based environment such as a call center, healthcare or retail location. Exceptional communication skills, written and verbal. Demonstrated competencies, problem solving and critical thinking skills. Computer and keyboard navigation skills.


The highest level of education desired for candidates in this position is a Associate's degree or equivalent experience.


Functional - Customer Service/Customer Service - Member Services - Traditional products/1-3 Years

Functional - Communications/Member communications/1-3 Years

Functional - Customer Service/Customer service - transaction based environment/1-3 Years

Functional - Customer Service/Customer service - production environment/1-3 Years


Technical - Desktop Tools/Microsoft Word/1-3 Years/End User

Technical - Desktop Tools/Microsoft Outlook/1-3 Years/End User

Technical - Desktop Tools/TE Microsoft Excel/1-3 Years/End User


Service/Creating a Differentiated Service Experience/ADVANCED

Service/Handling Service Challenges/ADVANCED

Service/Providing Solutions to Constituent Needs/FOUNDATION


Benefits Management/Interacting with Medical Professionals/FOUNDATION

General Business/Maximizing Work Practices/ADVANCED

Service/Demonstrating Service Discipline/FOUNDATION


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.

Job Function: Customer Service

Aetna is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected Veterans status.