Inbound/Outbound Queue Associate

CVS Health•Cypress, TX

About The Position

Supports the comprehensive coordination of medical services, including intake, screening, and referrals to Aetna Better Health, and promotes the quality and effectiveness of Healthcare Services. The associate handles inbound requests from members and providers and makes outbound calls to providers to provide information or obtain clinical information for medical authorization approvals. The role includes researching and entering member information in Aetna systems, verifying eligibility, coordination of benefits (COB), and benefits, and approving services that do not require medical review in accordance with the benefit plan. The associate supports precertification administration in compliance with applicable laws, regulations, NCQA standards, and company policies and procedures. The role requires accurate documentation that meets risk management, regulatory, and accreditation requirements; protecting confidential member information; and communicating with members, providers, Aetna Case Managers, Nurses, Medical Directors, and other relevant parties. The work schedule is between 8 a.m. and 6 p.m. Eastern Time, with no weekends. The work is sedentary and involves extended periods of sitting, talking, hearing, and keying, as well as visual acuity for reviewing documents and a computer monitor.

Requirements

1–2 years of experience working as a medical assistant, office assistant, or in other clinical or equivalent work.
High school diploma, GED, or equivalent experience.

Nice To Haves

1–2 years of call center experience.
1–2 years of prior authorization experience.
Associate degree.

Responsibilities

Coordinate medical services, including intake, screening, and referrals to Aetna Better Health.
Promote and support the quality and effectiveness of Healthcare Services.
Handle intake of calls from members or providers about services by telephone, fax, and EDI.
Build, research, and enter member information in Aetna systems.
Screen requests for appropriate referral from medical services staff.
Approve services that do not require medical review in accordance with the benefit plan.
Conduct non-medical research, including eligibility, COB, and benefits verification.
Maintain accurate and complete documentation that meets risk management, regulatory, and accreditation requirements.
Promote effective communication internally and externally with claim administrators, Plan Sponsors, third-party payers, members, families, and healthcare team members.
Protect the confidentiality of member information and follow company confidentiality policies.
Communicate with Aetna Case Managers when processing transactions for members active in the program.
Support precertification administration in compliance with applicable laws, regulations, NCQA standards, and company policies and procedures.
Make outbound calls to providers to provide information or obtain clinical information for medical authorization approvals.
Use Aetna systems, including MedCompass, QNXT, ProFAX, and ProPAT.
Communicate with Aetna Nurses and Medical Directors when processing transactions for members active in the program.