Member Services Representative

Call Center Representative II - Member Services.

Must live in the state of Oklahoma.

Day time shift. Must not be working a 2nd job or planning on working 2 jobs.

Job Summary:

Responsible for increasing member and provider satisfaction, retention, and growth by
efficiently delivering competitive services to members and providers through a fully
integrated organization staffed by knowledgeable, customer-focused professionals supported by exemplary technologies and processes. Customer Service Representative is the face of Aetna and impacts 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 members based upon the member’s unique needs, preferences and understanding of Aetna plans, tools and resources to help guide the members along a clear path to care.

Duties:

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. The CSR
• guides the member through their members 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 members by understanding and engaging the

member to the fullest to champion for our members' best health.

• Taking accountability to fully understand the member’s needs by building a trusting and

caring relationship with the member.

• Anticipates customer needs. Provides the customer with related information to answer

the unasked questions, e.g. additional plan details, benefit plan details, member self-service tools, etc.

• Uses customer service threshold framework to make financial decisions to resolve

member issues.

• 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

recredentialing issues.

• Responds to requests received from Aetna's Law Document Center regarding litigation;

Lawsuits.

• 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 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.

Min. Requirements:

- High School or GED equivalent.
- 1 year of 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 call production environment.

-1 year of Health insurance experience highly preferred.

Job Type: Temporary

Pay: $16.00 - $20.00 per hour

Benefits:

• 401(k)
• Dental insurance
• Flexible schedule
• Health insurance
• Paid time off
• Vision insurance

Experience level:

• 1 year

Schedule:

• 8 hour shift
• Day shift
• Monday to Friday

Education:

• High school or equivalent (Required)

Experience:

• Health Insurance: 1 year (Required)
• HIPAA: 1 year (Required)
• Medical terminology: 1 year (Required)
• Member or Custom Service: 1 year (Required)

Ability to Commute:

• Oklahoma City, OK 73139 (Required)

Ability to Relocate:

• Oklahoma City, OK 73139: Relocate before starting work (Required)

Work Location: Hybrid remote in Oklahoma City, OK 73139