This position is work at home for candidates residing in Pacific Standard Time Zone.Supports comprehensive coordination of medical services including intake, screening and referrals to Aetna Medical Services Programs. Promotes/supports quality effectiveness of Healthcare Services.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 informationScreens requests for appropriate referral to medical services staffApprove services that do not require a medical review in accordance with the benefit planPerforms non-medical research including eligibility verification, COB, and benefits verificationMaintains 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 confidentialityCommunicate with Aetna Case Managers, when processing transactions for members active in this ProgramSupports 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 proceduresPlaces outbound calls to providers under the direction of Medical Management Nurses to obtain clinical information for approval of medical authorizationsUses Aetna Systems such as QNXT, ProFAX, ProPAT, and Milliman CriteriaCommunicates with Aetna Nurses and Medical Directors, when processing transactions for members active in this ProgramSedentary work involving significant periods of sitting, talking, hearing and keyingWork 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.
2-4 years experience as a medical assistant, office assistant or other clinical experience.High School Diploma or G.E.D.
Please review required qualifications above
High School diploma, G.E.D. or equivalent experience
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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