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Aetna Provider Customer Service Representative in Phoenix, Arizona

Req ID: 61943BR

Job Description

The Provider Customer Service Representative is the face of Aetna and impacts the provider's and members' service experience by manner of how customer service inquiries and problems via telephone, internet or written correspondence are handled. Customer inquiries are of basic and at times complex nature. Engages, consults and educates providers based upon their unique needs, preferences and understanding of Aetna plans, tools and resources to help guide them as well as the members along a clear path to care.

Fundamental Components included but are not limited to:

Answers questions and resolves issues based on phone calls/letters from providers. Triages resulting rework to appropriate staff. Documents and tracks contacts with providers. The CSR guides the provider through their patient's 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 providers by understanding and engaging them to the fullest to champion for our members' best health. Taking accountability to fully understand the provider's needs by building a trusting and caring relationship. Anticipates customer needs. Provides the customer with related information to answer the unasked questions, e.g. additional plan details, benefit plan details, provider self-service tools, etc. Uses customer service threshold framework to make financial decisions to resolve issues. Explains provider's rights and responsibilities in accordance with contract. Processes claim inquiries, 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 compiling claim data for customer audits. 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.

Qualifications Requirements and Preferences:

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.

Functional Skills:

Customer Service - Customer service - production environment, Customer Service - FE Customer Service - Provider - Traditional

Required Skills:

Service - Creating a Differentiated Service Experience, Service - Handling Service Challenges, Service - Providing Solutions to Constituent Needs

Desired Skills:

General Business - Applying Reasoned Judgment, General Business - Communicating for Impact, Service - Demonstrating Service Discipline

Additional Job Information:

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.

Benefit Eligibility

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

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.