CVS Remote Customer Service Representative – Provider (WFH)

At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.

As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.

Must live in Eastern Time Zone

Training Schedule: M-F 8-430pm EST/ 8-10 Weeks

Post Training Schedule: Must be available to work between M-F 8-530pm EST

Position Summary

• Customer Service Representative is the face of Aetna and impacts members’ service experience by manner of how customer service inquiries and problems via telephone, internet or written correspondence are handled.
• Customer 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, providers, and plan sponsors.
• Triages resulting rework to appropriate staff.
• Documents and tracks contacts with members, providers, and plan sponsors.
• The CSR guides the member through their members 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 customer needs.
• Provides the customer with related information to answer the unasked questions, e.g., additional plan details, benefit plan details, member self-service tools, etc.
• Uses customer 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) via target system.
• Educates providers on our self-service options. Assists providers with credentialing and re-credentialing issues.
• 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 customer 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.

Required Qualifications

• Customer Service experiences in a transaction-based environment such as a call center, demonstrating ability to be empathetic and compassionate.
• Experience in a production environment.

Preferred Qualifications

• Medical Terminology and/or Provider office experience.
• Understanding of insurance concepts and processes.

Education

• High School or GED equivalent.