Job Description
Job Description
Sr. Customer Service Representative is the face of Aetna and impacts members' service experience by manner of how customer service inquiries and problems via telephone, internet or written correspondence are handled. Calls are typically non-routine and may require deviation from standard screens, scripts and procedures to engage, consult and educate members based upon the members unique needs, preferences and understanding of Aetna plans, tools and resources to help guide the members along a clear path to care. Act as subject matter expert by providing training, coaching, or responding to complex issues. May analyze and adjudicate claims.Answers questions and resolves issues as a "single-point-of-contact" based on phone calls, letters, and internet from brokers, marketing plan sponsors, PSS/ISO, members and providers. Activities may include providing claim status information, benefit coverage interpretations, and explaining plan eligibility. 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 members 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. Processes claim referrals, new claim hand-offs, nurse reviews, and member/provider complaints. Escalates issues as appropriate through the target system for grievances and appeals. Initiates out-reach/welcome calls to ensure constituents expectations are met or exceeded. Through in-depth analysis, identifies complaint trends and any emerging customer service issues and works to develop solutions to address potential problems. Educates customers on various elements of benefit plan information and available services created to enhance the overall customer service experience with the company (i.e., assistance with member self-service tools). Partners with other departments to deliver client specific presentations. Coordinates efforts both internally and across departments to successfully resolve service issues and develop process improvements intended to enhance the overall delivery of service. Serves as SME providing technical assistance when needed on call related issues, products, and/or system applications delivery matters. Coaches, trains and assists in the development of call center staff. May participate and/or lead special projects/initiatives addressing service issues. May provide technical or subject matter expertise concerning policies, procedures, and function-related applications/systems tools. Delivers internal quality reviews. Provides appropriate support in third party audits when required. Documents and tracks all contacts, events, and outcomes with clients using appropriate systems and processes.
Required Qualifications
Must Have: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.Demonstrated ability to handle multiple assignments competently, accurately and efficiently.Associate's degree or equivalent work experience.
Preferred Qualifications
Helpful to have Medicaid and or Medicare experience. Please review required qualifications above
Education
High School diploma, G.E.D. or equivalent experience
Business Overview
At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.
Sr. Customer Service Representative is the face of Aetna and impacts members' service experience by manner of how customer service inquiries and problems via telephone, internet or written correspondence are handled. Calls are typically non-routine and may require deviation from standard screens, scripts and procedures to engage, consult and educate members based upon the members unique needs, preferences and understanding of Aetna plans, tools and resources to help guide the members along a clear path to care. Act as subject matter expert by providing training, coaching, or responding to complex issues. May analyze and adjudicate claims.Answers questions and resolves issues as a "single-point-of-contact" based on phone calls, letters, and internet from brokers, marketing plan sponsors, PSS/ISO, members and providers. Activities may include providing claim status information, benefit coverage interpretations, and explaining plan eligibility. 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 members 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. Processes claim referrals, new claim hand-offs, nurse reviews, and member/provider complaints. Escalates issues as appropriate through the target system for grievances and appeals. Initiates out-reach/welcome calls to ensure constituents expectations are met or exceeded. Through in-depth analysis, identifies complaint trends and any emerging customer service issues and works to develop solutions to address potential problems. Educates customers on various elements of benefit plan information and available services created to enhance the overall customer service experience with the company (i.e., assistance with member self-service tools). Partners with other departments to deliver client specific presentations. Coordinates efforts both internally and across departments to successfully resolve service issues and develop process improvements intended to enhance the overall delivery of service. Serves as SME providing technical assistance when needed on call related issues, products, and/or system applications delivery matters. Coaches, trains and assists in the development of call center staff. May participate and/or lead special projects/initiatives addressing service issues. May provide technical or subject matter expertise concerning policies, procedures, and function-related applications/systems tools. Delivers internal quality reviews. Provides appropriate support in third party audits when required. Documents and tracks all contacts, events, and outcomes with clients using appropriate systems and processes.
Required Qualifications
Must Have: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.Demonstrated ability to handle multiple assignments competently, accurately and efficiently.Associate's degree or equivalent work experience.
Preferred Qualifications
Helpful to have Medicaid and or Medicare experience. Please review required qualifications above
Education
High School diploma, G.E.D. or equivalent experience
Business Overview
At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.
We are committed to maintaining a diverse and inclusive workplace. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.
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