Customer and Member Services

• Communicate with Aetna Case Managers, when processing transactions for members active in this Program.
• Supports the administration of the precertification process in compliance with various laws and regulations, URAQ and/or NCQA standards, where applicable, while adhering to company policy and procedures.
• Places outbound calls to providers under the direction of Medical Management Nurses to obtain clinical information for approval of medical authorizations. Uses Aetna Systems such as MedCompass, QNXT, ProFAX, ProPAT, and Milliman Criteria.
• Communicates with Aetna Nurses and Medical Directors, when processing transactions for members active in this Program.
• Sedentary work involving significant periods of sitting, talking, hearing and keying. Work requires visual acuity to perform close inspection of written and computer-generated documents as well as a PC monitor. Working environment includes typical office conditions.

Required Qualifications

• Must live in Ohio.
• Customer service experience, Microsoft Office, call center experience.
• Familiarity with basic medical terminology and concepts used in care management.
• Computer literacy in order to navigate through internal/external computer systems, including Excel and Microsoft Word.
• Ability to work on a rotation schedule for weekends/holidays.

Preferred Qualifications

• 2-4 years experience as a medical assistant, office assistant or other clinical experience, call center experience.
• Effective communication, telephonic and organization skills.
• Strong customer service skills to coordinate service delivery including attention to customers, sensitivity to issues, proactive identification and resolution of issues to promote positive outcomes for members.

Education

• High School diploma, G.E.D. or equivalent experience