Req ID: 34485BR
POSITION SUMMARY
In the Inbound/ Outbound Queue Associate position, you will perform prior authorization for members with Medicare and Medicaid eligibility questions. Candidates should be comfortable on the phone and taking multiple calls.
Fundamental Components & Physical Requirements include but are not limited to:
*
* Performs intake of calls from members or providers regarding services via telephone, fax, EDI.
* Utilizes eTUMS and other Aetna system to build, research and enter member information.
* Screens requests for appropriate referral to medical services staff.
* Approve services that do not require a medical review in accordance with the benefit plan.
* Performs non-medical research including eligibility verification, COB, and benefits verification.
* Maintains accurate and complete documentation of required information that meets risk management, regulatory, and accreditation requirements.
Fundamental Components:
* Fundamental Components & Physical Requirements include but are not limited to:
* Performs intake of calls from members or providers regarding services via telephone, fax, EDI.
* Utilizes eTUMS and other Aetna system to build, research and enter member information.
* Screens requests for appropriate referral to medical services staff.
* Approve services that do not require a medical review in accordance with the benefit plan.
* Performs non-medical research including eligibility verification, COB, and benefits verification.
* Maintains accurate and complete documentation of required information that meets risk management, regulatory, and
* accreditation requirements.
* Promotes communication, both internally and externally to enhance effectiveness of medical management services
* (e.g., claim administrators, Plan Sponsors, and third party payers as well as member, family, and health care team
* members respectively)
* Protects the confidentiality of member information and adheres to company policies regarding confidentiality
* 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 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.
BACKGROUND/EXPERIENCE desired:
* Education and Certification Requirements
* Additional Information (situational competencies, skills, work location requirements, etc.)
* 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.
* Computer literacy; Required
* Call Center Experience; Very Strong Preference
* 1 year or more Doctor's office or insurance verification experience; Plus
* Medical Terminology; Required
EDUCATION
The minimum level of education desired for candidates in this position is a High School diploma, G.E.D. or equivalent experience.
REQUIRED SKILLS
Benefits Management/Interacting with Medical Professionals/ADVANCED
Benefits Management/Promoting Health Information Technology/ADVANCED
Benefits Management/Understanding Clinical Impacts/FOUNDATION
DESIRED SKILLS
General Business/Communicating for Impact/ADVANCED
Service/Case Administration/ADVANCED
Service/Demonstrating Service Discipline/FOUNDATION
Telework Specifications:
Option for telework will be evaluated after a certain period of employment
Telework considered only for unique circumstances
ADDITIONAL JOB INFORMATION
Aetna is about more than just doing a job. This is our opportunity to re-shape healthcare for America and across the globe. We are developing solutions to improve the quality and affordability of healthcare. What we do will benefit generations to come.
We care about each other, our customers and our communities. We are inspired to make a difference, and we are committed to integrity and excellence.
Together we will empower people to live healthier lives.
Aetna is an equal opportunity & affirmative action employer. All qualified applicants will receive consideration for employment regardless of personal characteristics or status. We take affirmative action to recruit, select and develop women, people of color, veterans and individuals with disabilities.
We are a company built on excellence. We have a culture that values growth, achievement and diversity and a workplace where your voice can be heard.
We conduct pre-employment drug and background testing. Benefit eligibility may vary by position. Clickhereto review the benefits associated with this position.
Job Function: Health Care