Member Services Specialist - Healthcare Plans

Aetna; Frankfort (KY); Remote; USD 27,552 - 41,328; Full time

Job summary

Aetna in Frankfort, KY is seeking a Customer Service Representative to support members and providers. You will handle inquiries via phone, email, or written correspondence, educate members on plan benefits, and resolve issues with empathy.

The role requires a Bachelor's degree and experience in a transaction-based environment, preferably call-center, with Medicare/Medicaid terminology understanding.

Qualifications

• Customer service experience in a transaction-based environment, preferably in a call center.
• Ability to be empathetic and compassionate.
• Experience in a production environment.
• Experience offering customer support to senior populations and understanding of clinical terminology, Medicare and Medicaid regulations.

Responsibilities

• Provide customer support inquiries and problems through phone, internet or written correspondence.
• Engage, consult, and educate members based on their wishes and Aetna plans.
• Answer questions and resolve problems primarily based on phone calls or written communications.
• Triage cases to suitable staff and track contacts with contributors, companies and plan sponsors.
• Provide guidance on plan benefits and policy.
• Build trust and relationships with members, anticipating needs.
• Provide related information such as extra plan details, benefit statements and member self-service tools.
• Use customer support frameworks to resolve issues and explain member rights and responsibilities.
• Handle referrals, new claim handoffs, nurse critiques, court cases, grievances and appeals.
• Educate carriers, assist with credentialing and re‑credentialing issues.
• Respond to regulatory requests, handle complaints and educational reports.
• Compile claim statistics for audits, determine scientific necessity, coverage provisions and member eligibility.
• Handle requests for appeals and pre‑authorizations, monitor benefit limits and financial responsibility.
• Prepare letters and spreadsheets responding to inquiries.

Skills

Customer service experience

Empathy & compassion

Production environment experience

Support for senior populations

Clinical terminology knowledge

Education

Bachelor's degree

Job description

Aetna in Frankfort, KY is seeking a Customer Service Representative to support members and providers. You will handle inquiries via phone, email, or written correspondence, educate members on plan benefits, and resolve issues with empathy.

The role requires a Bachelor's degree and experience in a transaction-based environment, preferably call-center, with Medicare/Medicaid terminology understanding.