At Aetna, sometimes we have to make difficult decisions about whether or not a medical service is covered. In the past, how did you put aside your personal feelings for the good of the business?
In the health insurance and claims industry at Aetna, you may have to make difficult decisions, and some of them don't feel great. Your interviewer needs to know that the candidate they hire will come with the ability to face these difficult decisions with ease and class.
"I was working with a patient who had a procedure that wasn't covered. There was an alternative that was covered, but she had decided that wasn't the best route for her to take. I felt awful giving her this news, but I knew I couldn't approve of it. I did mention the scenario to my leader to double-check I had done the right thing, and she verified that I made a good call."
"I have a lot of empathy for others, so these situations are hard. I worked with a gentleman who had a denied claim and tried to point him in the direction of community resources that could help him pay for some of his expenses. I also referred him to a social worker at the hospital where he had his surgery to see what resources and payment plans they could come up with for him. I tried to give him the best service and look into as many alternatives as possible."
Ensure the interviewer knows you can handle a difficult situation and do your job effectively by talking about a work situation in your past where you had to make a difficult decision that impacted others. You want to make sure your interviewer knows why this decision was important, how you communicated it to those impacted and what the result was.
Community answers are written by other candidates practicing this set. Reading how others frame the same question is one of the fastest ways to sharpen your own.
Anonymous Answer
There was a situation with a member who needed an expensive surgery for TMJ. Her doctor submitted the predetermination letter and it was denied. It was further reviewed by our Medical Director and completed all levels of the appeal process and the denial was maintained. Throughout all of this time, I was in frequent contact with the member and it was very difficult as she said she was in so much pain and I felt terrible for her, but each time we got another denial I would have to speak with her. After a review with her plan sponsor, we decided to do one last external review for her. I found a provider outside the company who was willing to do the review and unfortunately he also agreed that services were not medically necessary. I notified the plan sponsor and they asked me to notify the member. She was devastated and I felt for her. I let her know how sorry I was that things had not turned out differently and we parted as friends. Ultimately it was my role to administer the benefits as they were written.
Amanda's Feedback
Fantastic example! You've illustrated your ability to empathize with the customer and take all appropriate steps to make a fully-informed decision. Even when that decision didn't see the customer's expectations you were still able to make the decision in alignment with plan guidelines and communicate it in a way that was thoughtful.
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