-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.
-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.
Required Qualifications
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.