Customer Service New Business Operations
About The Position
We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary 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.
Requirements
- 3 days onsite Tuesday-Thursday in Franklin, TN
- 1-3 years Customer Service experiences in a transaction based environment such as a call center or retail location preferred.
- Demonstrating ability to be empathetic and compassionate.
- Experience in a production environment.
- High School Diploma
Nice To Haves
- Proficient in Excel.
- SQL experience a plus
- Insurance Knowledge - Plus
Responsibilities
- 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.
Benefits
- This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families.
- The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.
- Additional details about available benefits are provided during the application process and on Benefits Moments.
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
Education Level
High school or GED
Number of Employees
5,001-10,000 employees
