Supports comprehensive coordination of medical services
including intake, screening and referrals to Aetna Better Health.
Promotes/supports quality effectiveness of Healthcare Services.
Performs intake of calls from members or providers regarding services via telephone, fax, EDI.
Utilizes Aetna system to build, research and enter member
Screens requests for appropriate referral to
medical services staff.
Approve services that do not require
a medical review in accordance with the benefit
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 and/or NCQA standards, where applicable, while adhering to company policy and procedures.
Places outbound calls to providers to provide information or obtain clinical information for approval of medical authorizations.
Uses Aetna Systems such as QNXT,ProFAX and ProPAT.
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..
The typical pay range for this role is:
Please keep in mind that this range represents the pay range for all positions in the job grade within which this position falls. The actual salary offer will take into account a wide range of factors, including location.
1-2 year's experience working as a medical assistant, office assistant or other clinical/equivalent experience.
Call center experience is preferred plus 2-4 year's experience working as a medical assistant, office assistant or other clinical/equivalent experience.
High School Diploma, GED or equivalent experience.
Bring your heart to CVS Health Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand — with heart at its center — our purpose sends a personal message that how we deliver our services is just as important as what we deliver. Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable. We strive to promote and sustain a culture of diversity, inclusion and belonging every day. CVS Health is an affirmative action employer, and is an equal opportunity employer, as are the physician-owned businesses for which CVS Health provides management services. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law. 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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