Customer Service, New Business Operations- Hybrid Franklin, TN

CVS Health•Franklin, TN

10d•Hybrid

About The Position

CVS Health is seeking a compassionate, customer-focused Customer Service Representative to support customers, including benefit plan members, employers, physicians, hospitals, and other healthcare providers. The representative researches issues, documents outcomes, resolves inquiries, and works to deliver high customer satisfaction by listening and responding to customer needs. The role focuses on building trusting relationships with members, understanding their needs, anticipating questions, and providing relevant benefit and plan information. It also supports providers, handles claim and appeal-related processes, reviews coverage and eligibility, and performs administrative and financial data tasks. The position is hybrid, with onsite work Tuesday through Thursday in Franklin, Tennessee.

Requirements

High school diploma.
Ability to demonstrate empathy and compassion.
Experience in a production environment.

Nice To Haves

1–3 years of customer service experience in a transaction-based environment, such as a call center or retail location.
Proficiency in Excel.
SQL experience.
Insurance knowledge.

Responsibilities

Build emotional connections with members by understanding and engaging with them to support their health.
Take accountability for understanding member needs and building trusting, caring relationships.
Anticipate customer needs and provide relevant information, including plan details, benefits, and self-service tools.
Use the customer service threshold framework to make financial decisions that resolve member issues.
Explain members’ rights and responsibilities in accordance with their contracts.
Process claim referrals, new claim handoffs, nurse reviews, complaints, grievances, and appeals through the target system.
Educate providers about self-service options and assist with credentialing and re-credentialing issues.
Respond to requests from Aetna’s Law Document Center regarding litigation and lawsuits.
Handle extensive file review requests.
Assist in preparing complaint trend reports.
Assist in compiling claim data for customer audits.
Determine medical necessity and applicable coverage provisions, and verify member plan eligibility for incoming correspondence and internal referrals.
Handle incoming appeal and pre-authorization requests not handled by Clinical Claim Management.
Review member claim history to ensure accurate tracking of benefit maximums, coinsurance, and deductibles.
Perform financial data maintenance as necessary.
Use applicable system tools and resources to produce quality letters and spreadsheets in response to inquiries.