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Member Services Representative - Feb Start
Rancho Cordova, CA
START: Feb 17, 2020
The Customer Service Representative is the face of our company and impacts members and providers' 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 and providers based upon the caller's unique needs, preferences and understanding of our plans, tools and resources to help guide the members along a clear path to care.
- 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, 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 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.
- Uses applicable system tools and resources to produce quality letters and spreadsheets in response to inquiries received.
- 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.
- High School or GED equivalent.
- Ideal to be fluent in Spanish/English
Shift: Monday-Friday, start time varies from 6am-11:30am.