- Supports comprehensive coordination of medical services including intake, screening, and referrals.
- 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 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 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 MedCompass, 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.
Required Qualifications- 1-2 years’ experience working as a medical assistant, office assistant or other clinical/equivalent experience
Preferred Qualifications- Call center experience is preferred, 1-2 years
- Prior authorization experience, 1-2 years
Education- Associates degree, preferred
- High School Diploma, GED or equivalent experience.
Work from Home Requirements:
• You must have or be able to obtain a direct/hardwired internet connection to a modem/router within 7 feet of your computer and
a minimum download speed of 25 mbs download and 3 mbs upload. WiFi and satellite internet are not permitted.
• A quiet, secure and private designated home virtual work location, free from distractions, tidy and organized, compliant with CVS
Health and HIPAA guidelines, and allowing for uninterrupted work during work hours.
• Work-from-Home colleagues are required to work within the state and city where they have confirmed they currently live.
• The company will provide equipment (keyboard, monitor, computer, headset, etc.). All new hires should provide their own
workspace furniture (desk or standing desk, as this position would require you to be at your desk for extended periods of time).
• If hired, you will commit to obtaining required internet speeds and adhere to all Work From Home requirements.
Technical and Logistical Requirements:
• Device & System Navigation: Comfortable setting up and using multiple monitors and navigating multiple applications
simultaneously to streamline tasks and improve efficiency.
• Communication Tools: Ability to communicate on digital channels such as via email, calendar invites, Teams messaging, and
virtual meetings.
• Collaboration & Scheduling: Experience with Microsoft Office 365 (Teams, Outlook, Word, Excel, PowerPoint) applications or
similar (Google Workspace).
• Systems Access & Security: Ability to Log in to secure systems (e.g., VPN, EHR portal), lock a computer screen when
unattended, manage strong passwords, and recognize suspicious emails or links.
• Troubleshooting & Support: Ability to resolve common technical issues independently, such as: restarting an application when
frozen, resolving internet connection issues, and contacting IT for unresolved technical issues.
• Future Growth: Openness to learning new skills in the future as the workplace environment evolves
