Healthcare Customer Service

A-Line Staffing Solutions
November 8, 2020
Blue Bell, PA
Job Type


Now hiring Pharmacy Appeals Rep in San Antonio, Texas. This Pharmacy Appeals Rep position is with a Fortune 500 company and has career growth potential.

If interested, please apply.

Jacob Zambuto
[Click Here to Email Your Resumé]

Pharmacy Appeals Rep Processor Highlights:

  • Pay starts at $13 per hour
  • Mon-Fri 8:30-5:00

Pharmacy Appeals Rep Job Description:

This is a Member Services Call Center role.
Minimum 35 to 50 Calls per day.

Member Services Representative (MSR) is the face of Aetna and impacts members' service experience by manner of how member service inquiries and problems via telephone, internet or written correspondence are handled. Member inquiries are of basic and at times complex nature. Engages, consults and educates members based upon the member’s unique needs, preferences and understanding of Aetna plans, tools and resources to help guide the members along a clear path to care.

• Answers questions and resolves issues based on phone calls/letters from members, parents/guardians, and providers. Triages resulting rework to appropriate staff. Documents and tracks contacts with members, parents/guardians and providers. The MSR guides the member through their member’s 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 member needs. Provides the member with related information to answer the unasked questions, e.g. additional plan details, benefit plan details, member self-service tools, etc. (*)
• Uses member 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) through call tracking and guidelines provided in desktops and policies. (*)
• 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 member 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. (*)
• Exhibits the following Member Service Representative Behaviors

Pharmacy Appeals Rep Job Requirements:

* Minimum of 1 year in a customer service or call center environment (call center type environments preferred, if doctors office then anything below managing 75 calls/day would not translate to similar environment). * Must have effective and empathetic communication style in managing inbound calls and communications with clients and team members. * Computer experience is required with proficiency in Microsoft Outlook, Word and Excel. * Basic alpha number data entry skills with attention to accuracy and quality is essential. * Intermediate math skills are required with attention to detail and quality essential. * Experience in a health care setting or insurance industry is a plus, including knowledge of basic insurance and third party terms and medical terminology. * Ability to work with people in a team environment while meeting individual performance goals. * Must be able to read and interpret policies, procedures and instructions. * Effective organizational skills and ability to prioritize a fluctuating workload and competing priorities is essential.


  • Full benefits available after 90 days: Medical, Dental, Vision, Life, Short-term Disability
  • 401k after 1 year of employment: With employer match and profit sharing
  • Competitive Pay Rate!

If interested, please apply to this job posting right away. I look forward to hearing from you!
Jacob Zambuto
[Click Here to Email Your Resumé]

Medical, healthcare, Medicare, Medicaid, data entry, call center, customer service, provider billing, claims processing, pharmacy, appeals

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