Inbound/Outbound Queue Associate ID-16101

May 27, 2025

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Shift: Monday-Friday, 3:00pm - 12:00am EST

Position Summary

Supports comprehensive coordination of medical services including intake, screening and referrals to Aetna Medical Services Programs.

Responsibilities

- 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.

- Working environment includes typical office conditions.

Required Qualifications

- 2-4 years experience as a medical assistant, office assistant or other clinical experience.

- Must Reside in the State of Virginia

Education

High School diploma or equivalent GED

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