Job Description

Job Description
Supports comprehensive coordination of medical services including intake, screening and referrals to Aetna Medical
Services Programs. Promotes/supports quality effectiveness of Healthcare Services.

Required Qualifications
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. Working
environment includes typical office conditions.

Preferred Qualifications
2-4 years experience as a medical assistant, office assistant or other clinical experience
Strong customer service skills to coordinate service delivery including attention to customers, sensitivity to issues,
proactive identification and resolution of issues to promote positive outcomes for members.
Computer literacy in order to navigate through internal/external computer systems, including Excel and Microsoft Word.
Ability to effectively participate in a multi-disciplinary team including internal and external participants.
Familiarity with basic medical terminology and concepts used in care management.
Effective communication, telephonic and organization skills.

Education
High School Diploma or G.E.D.

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.