Customer Service Representative – Hcb Ops

Customer Service Representative – Hcb Ops

Requirements

• Experience in a production environment.
• Customer Service experiences in a transaction based environment such as a call center or retail location preferred, demonstrating ability to be empathetic and compassionate.
• High School diploma, G.E.D. or equivalent experience.

Responsibilities

• Handle customer service inquiries and problems via telephone, internet or written correspondence.
• Engage, consult and educate members based on their unique needs and understanding of Aetna plans.
• Answer questions and resolve issues based on phone calls/letters from members, providers, and plan sponsors.
• Document and track contacts with members, providers and plan sponsors.
• Guide the member through their plan of benefits, Aetna policy and procedures.
• Create an emotional connection with members by understanding and engaging them.
• Provide customers with related information to answer unasked questions.
• Use customer service threshold framework to make financial decisions to resolve member issues.
• Explain member’s rights and responsibilities in accordance with contract.
• Process claim referrals, new claim handoffs, nurse reviews, complaints, grievance and appeals via target system.
• Educate providers on self-service options and assist with credentialing issues.
• Respond to requests from Aetna’s Law Document Center regarding litigation and lawsuits.
• Assist in preparation of complaint trend reports and compiling claim data for customer audits.
• Determine medical necessity, applicable coverage provisions and verify member plan eligibility.
• Handle incoming requests for appeals and pre-authorizations not handled by Clinical Claim Management.
• Perform review of member claim history to ensure accurate tracking of benefit maximums and/or coinsurance/deductible.
• Perform financial data maintenance as necessary.
• Use applicable system tools and resources to produce quality letters and spreadsheets in response to inquiries received.
• Take inbound Brokerage calls to provide application status, contract and appointment status.
• Review commission inquiries, data entry, processing of Medicare contracts, appointments and verification of certification for external producers/agents.

Preferred Qualifications

• Customer Service experiences in a transaction based environment such as a call center or retail location preferred.