Customer Service Representative, New Business Operations

Position Summary

We are seeking a compassionate, customer‑obsessed Customer Service Representative to care for our customers, including members, employers, doctors, hospitals, and other providers. In this role, you will create connections with customers by helping with their benefits and claims to improve their health and well‑being. You will educate customers about their benefits and claims while resolving issues and directing them to helpful resources.

This position requires adaptability and empathy, as you will be handling a variety of inquiries and ensuring customer satisfaction through kind and respectful interactions.

As the face of our company, you will research issues, document outcomes, resolve inquiries, and deliver a high level of customer satisfaction. Your ability to listen and respond to customer needs is crucial in inspiring trust and loyalty.

• Creates an emotional connection with our members by understanding and engaging the member to the fullest to champion for our members' best health.
• Taking accountability to fully understand the member’s needs by building a trusting and caring relationship with the member.
• Anticipates customer needs.
• Provides the customer with related information to answer the unasked questions, e.g. additional plan details, benefit plan details, member self‑service tools, etc.
• Uses customer service threshold framework to make financial decisions to resolve member issues.
• Explains member's rights and responsibilities in accordance with contract.
• Processes claim referrals, new claim handoffs, nurse reviews, complaints (member/provider), grievance and appeals (member/provider) via target system.
• Educates providers on our self‑service options; assists providers with credentialing and re‑credentialing issues.
• Responds to requests received from Aetna's Law Document Center regarding litigation; lawsuits handles extensive file review requests.
• Assists in preparation of complaint trend reports.
• Assists in compiling claim data for customer audits.
• Determines medical necessity, applicable coverage provisions and verifies member plan eligibility relating to incoming correspondence and internal referrals.
• Handles incoming requests for appeals and pre‑authorizations not handled by Clinical Claim Management.
• Performs review of member claim history to ensure accurate tracking of benefit maximums and/or coinsurance/deductible.
• Performs financial data maintenance as necessary.
• Uses applicable system tools and resources to produce quality letters and spreadsheets in response to inquiries received.

• 3 days onsite Tuesday-Thursday in Franklin, TN
• 1‑3 years of Customer Service experience in a transaction‑based environment such as a call center or retail location preferred.
• Demonstrating ability to be empathetic and compassionate.
• Experience in a production environment.

• Proficient in Excel.
• SQL experience a plus.
• Insurance Knowledge – Plus.

• High School Diploma

40

Full time

The typical pay range for this role is: $17.00 - $28.46. This pay range represents the base hourly rate or base annual full‑time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors.

This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.

Additional details about available benefits are provided during the application process and on Benefits Moments.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.