Inbound Outbound Queue Associate (Fully Remote)
Promotes/supports the functions of the Utilization clinical and non-clinical team.
Promotes/supports quality effectiveness of Healthcare Services.
Performs intake of calls from members or providers regarding services via telephone, fax, EDI.
Utilizes QNXT, iNotify, EMR and other Aetna system to build, create, 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, 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.
- Candidate must work in Eastern Standard Time Zone.
- 2-4 years of experience in managed care/managed long
- Experience with MS Word; Excel; Outlook; telephony
systems; WebEx; Microsoft Teams
- Associates or Bachelors degree preferred
- Experience in NYS Managed Long Term Care
- Experience in Medicare and Medicaid benefit coordination;
utilization management/care management.
High School Diploma or G.E.D
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.