Aetna CA MCD Customer Service Rep in San Diego, California
Req ID: 50478BR
The Member Services Rep handles member services inquiries and problems via telephone, internet or written correspondence. Member inquiries are of basic and of routine nature.
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. Responsibilities include: 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. 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. 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. Bilingual skills, Spanish speaking is a plus.
The highest level of education desired for candidates in this position is a High School diploma, G.E.D. or equivalent experience.
Functional - Customer Service/Customer service - production environment/1-3 Years
Functional - Customer Service/Customer service - transaction based environment/1-3 Years
Functional - Customer Service/Customer Service - Member Services - Traditional products/1-3 Years
Functional - Communications/Member communications/1-3 Years
Technical - Desktop Tools/Microsoft Outlook/1-3 Years/
Technical - Desktop Tools/Microsoft Word/1-3 Years/
Technical - Desktop Tools/TE Microsoft Excel/1-3 Years/
Technical - Desktop Tools/Microsoft SharePoint/1-3 Years/
Service/Demonstrating Service Discipline/FOUNDATION
Service/Creating a Differentiated Service Experience/ADVANCED
Service/Providing Solutions to Constituent Needs/FOUNDATION
Service/Working Across Boundaries/ADVANCED
Service/Handling Service Challenges/ADVANCED
Leadership/Fostering a Global Perspective/FOUNDATION
ADDITIONAL JOB INFORMATION
Are you ready to join a company that is changing the face of health care across the nation? Aetna Better Health of California is looking for people like you who value excellence, integrity, caring and innovation. As an employee, youll join a team dedicated to improving the lives of the most vulnerable in our population. Our vision incorporates community-based health care that works. We value diversity. Align your career goals with Aetna Better Health of California, and we will support you all the way.
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 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.
Job Function: Customer Service