Customer Service Representative, CVS Health

CVS Health

Location:
United States, Work At Home, North Carolina

Category:
Customer Service

Contract Type:
Employment contract

Salary:

17.00 - 25.65 USD / Hour

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Job Description:

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.

Job Responsibility:

Handle customer service inquiries and problems via telephone, internet or written correspondence
Engage, consult, and educate members based upon the member’s unique needs, preferences and understanding of Aetna plans, tools, and resources
Answer questions and resolve issues based on phone calls/letters from members, providers, and plan sponsors
Triage resulting rework to appropriate staff
Document and track contacts with members, providers, and plan sponsors
Guide the member through their members plan of benefits, Aetna policy and procedures
Create an emotional connection with our members by understanding and engaging the member to the fullest to champion for our members' best health
Anticipate customer needs
Provide the customer with related information to answer the unasked questions
Use customer service threshold framework to make financial decisions to resolve member issues
Explain member's rights and responsibilities in accordance with contract
Process claim referrals, new claim handoffs, nurse reviews, complaints (member/provider), grievance and appeals (member/provider) via target system
Educate providers on our self-service options
Assist providers with credentialing and re-credentialing issues
Respond to requests received from Aetna's Law Document Center regarding litigation; lawsuits
Handle extensive file review requests
Assist in preparation of complaint trend reports
Assist in compiling claim data for customer audits
Determine medical necessity, applicable coverage provisions and verifies member plan eligibility relating to incoming correspondence and internal referrals
Handle incoming requests for appeals and pre-authorizations not handled by Clinical Claim Management
Perform review of member claim history to ensure accurate tracking of benefit maximums and/or coinsurance/deductible
Perform financial data maintenance, as necessary
Use applicable system tools and resources to produce quality letters and spreadsheets in response to inquiries received

Requirements:

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
Medical Terminology and/or Provider office experience
Understanding of insurance concepts and processes
High School or GED equivalent

Nice to have:

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

What we offer:

Affordable medical plan options
401(k) plan (including matching company contributions)
Employee stock purchase plan
No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching
Paid time off
Flexible work schedules
Family leave
Dependent care resources
Colleague assistance programs
Tuition assistance
Retiree medical access

Additional Information:

Job Posted:
April 26, 2025

Expiration:
May 06, 2025

Employment Type:

Fulltime

Work Type:

Remote work

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Customer Service Representative