Supports comprehensive coordination of medical services including intake, screening and referrals to Aetna Better Health. 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 QNXT, MedCompass, FaxHub 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.
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