Member Services Representative, CVS Health

CVS Health

Location:
United States, Florida

Category:
Customer Service

Contract Type:
Employment contract

Salary:

17.00 - 25.65 USD / Hour

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Job Description:

The role of Member Services Representative at CVS Health involves addressing customer service inquiries and problems, educating and guiding members about Aetna plans, tracking contacts, and ensuring compliance with regulatory guidelines. The CSR creates emotional connections with members, resolves member issues, and performs tasks such as processing claims, file reviews, and data maintenance.

Job Responsibility:

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
Guides the member through their member 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
Takes 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.

Requirements:

2 years- Customer service experience in a call center or retail location
Must reside in Florida preferably within 50 miles of either the Jacksonville or Plantation office.

Nice to have:

Trauma informed care training
Exposure to Care Management
Experience in a production environment
Familiarity with de-escalations
1-2 years of Healthcare or Medicaid experience
Telework experience
Bilingual is a plus.

What we offer:

Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan
No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching
Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

Additional Information:

Job Posted:
May 23, 2025

Expiration:
June 30, 2025

Employment Type:

Fulltime

Work Type:

Remote work

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Member Services Representative