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Position Summary

We are currently recruiting top talent for our Center of Excellence Customer Service group.

-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 location preferred, demonstrating ability to be empathetic and compassionate.
Experience in a production environment.
Prior experience providing customer service to the senior population, knowledge of medical terminology including Medicare and Medicaid policies
Must have high speed internet with consistent speeds above 25mbps and adherence to telework agreement

Preferred Qualifications

Please see qualifications above

Education

High School diploma, G.E.D. or equivalent experience

Anticipated Weekly Hours

Time Type

Full time

Pay Range

The typical pay range for this role is:

$17.00 - $34.15

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors.

In addition to your compensation, enjoy the rewards of an organization that puts our heart into caring for our colleagues and our communities. The Company offers a full range of medical, dental, and vision benefits. Eligible employees may enroll in the Company’s 401(k) retirement savings plan, and an Employee Stock Purchase Plan is also available for eligible employees. The Company provides a fully-paid term life insurance plan to eligible employees, and short-term and long term disability benefits. CVS Health also offers numerous well-being programs, education assistance, free development courses, a CVS store discount, and discount programs with participating partners. As for time off, Company employees enjoy Paid Time Off (“PTO”) or vacation pay, as well as paid holidays throughout the calendar year. Number of paid holidays, sick time and other time off are provided consistent with relevant state law and Company policies.

For more detailed information on available benefits, please visit Benefits | CVS Health

We anticipate the application window for this opening will close on: 03/01/2025

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

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