SANDRA EVANS

• Answers questions and resolves issues based on phone calls/letters from members, providers, and plan sponsors
• Triages resulting rework to appropriate staff.
• Documents and tracks contacts with members, providers and plan sponsors
• The CSR guides the member through their members plan of benefits, Aetna policy and procedures as well as having knowledge of resources to comply with any regulatory guidelines.
• 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

Qualifications Requirements and Preferences:

• Customer Service experiences in a transaction based environment such as a call center or retail location preferred
• Ability to be empathetic and compassionate.
• Experience in a production environment
• High School or GED equivalent

• Applied knowledge of medical terminology, medical billing guidelines, and fee schedules, Including CPT/ICD/HCPS coding and Knowledge of UB-O4 and CMS- 1500 form types.
• Researched CPT and ICD-10 coding discrepancies for compliance and reimbursement accuracy for over 150 bills per day.
• Located errors and promptly refiled rejected claims.
• Identified appropriateness of charges and associated coding on bills assigned daily.
• Calculated and applied savings associated with reviews.
• Communicate findings with stakeholders and supervision.
• Comply with customer special handling and jurisdictional guidelines.
• Utilize written and online resources support good decision making.
• Utilize review system to appropriately document work and final conclusions.

• Obtained benefits and prior approval from patient’s insurance carrier for all surgical cases.
• Documented benefits and prior approval including notes in PM Alert system.
• Acted as effective liaison between patient, surgeon, primary care physician, insurance company, hospital, and patient surgery coordinator in disseminating insurance benefits.
• Assessed situations and forwarded to physican's team or other staff as appropriate.
• If needed, prepared and mailed PreCert information so that the patient will receive it in a timely manner.
• Maintained accurate account of all surgical insurance verifications electronically.
• Working knowledge of patient management systems including insurance, information, and verification modules.
• Knowledge of Retina processes within precert dept to be able to obtain the most accurate authorization needed for the patient. ( buy and bill, specialty pharmacy, samples vs stock, Step Therapy, benefits investigations, and financial assistance).
• Applied necessary communication in the PM and EHR alerts to the clinical teams.
• Maintained knowledge of Cornea Cross Linking procedure to accurately obtain prior authorization, pre-determination. Communicates benefits and collection amounts with the patient prior to the surgery being scheduled. Completes HER telephone call log for accurate communication with the clinical teams.
• Maintained and obtained necessary VA authorizations for all HEC services provided to veteran patients.
• Obtained prior authorizations for necessarily ordered radiology (MRI’s, and CT Scans) for HEC providers.
• Ensured patient confidentiality and adheres to HIPAA requirements using all methods necessary including non-disclosure to unauthorized personnel, limiting record access and shredding discarded patient information.