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, company 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.

Experience/Requirements:

• High School or GED equivalent.
• Customer Service experiences in a transaction-based environment such as a call center or retail location preferred, demonstrating ability to be empathetic and compassionate.
• Healthcare insurance experience is preferred.
• Must have reliable internet, with a minimum speed requirement of  25 mbps/ 3mbps.
• A hardwired connection is required (ethernet connection); a wireless connection will introduce the risk of performance degradation.

Choice One Staffing Group offers medical, holiday pay, vacation pay, referral bonuses and pre-employment preparation. Choice One Staffing Group, Inc. is an equal opportunity employer that prohibits employment discrimination based on race, color, religion, sex, national origin and ancestry, individuals who are 40 years of age and older or qualified individuals with disabilities.