, Ohio

Job Description
This is a permanent work from home position from any US state.

• 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 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, URAQ and/or NCQA standards, where applicable, while adhering to company policy and procedures.
• Places outbound calls to providers under the direction of Medical Management Nurses to obtain clinical information for approval of medical authorizations Uses Aetna Systems such as QNXT, ProFAX, ProPAT, and Milliman Criteria.
• 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
2-4 years experience as a medical assistant, office assistant or other clinical experience.High School Diploma or G.E.D.

Preferred Qualifications
Please review required qualifications above

Education
High School diploma, G.E.D. or equivalent experience

Business Overview
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. See Job Description

, Ohio

Continue serving and work with a purpose

As a CVS Health colleague, you'll find career opportunities across the organization and at every stage of your career. More important, your work will have an impactful purpose on someone's life, including your own. Learn more about how you can continue serving on your next mission at CVS Health.

Careers for Veterans and Military Spouses

 

"The military has an ethos that is grounded in purpose-driven service that’s bigger than the individual. The same holds true for us at CVS Health. You can talk to colleagues in any part of our business and they will be able to articulate our company’s purpose. Working here provides an opportunity for service members and military spouses to continue to serve, just in a civvies."

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