Job Title: Remote Member Services Representative

Pay: $18 an hr | Bi-weekly

Job Type:

• Remote in Oklahoma

Shift Options:

• 8AM-5PM M-F CST

Remote Member Services Representative Overview:

• 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, Aetna 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.

Remote Member Services Representative Qualifications:

• •Must live in Oklahoma
• 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.
  • Experience in a production environment.

Remote Member Services Representative Benefits:

• Benefits are available to full-time employees after 90 days of employment and include health, optical, dental, life, and short-term disability insurance.
• A 401(k) with a company match is available for full-time employees with 1 year of service on our eligibility dates.

How to Apply:

If you are interested in this position, please apply OR submit your resume to:

Saw Hlaing | shlaing@alinestaffing.com | 412-790-5425