Customer Service, New Business Operations- Hybrid Franklin, TN

CVS Health•Franklin, TN

12d•$17 - $28•Hybrid

About The Position

CVS Health is seeking a compassionate, customer-focused Customer Service Representative to support members of benefit plans, employers, and healthcare providers. The representative researches issues, documents outcomes, resolves inquiries, and works to deliver a high level of customer satisfaction by listening and responding to customer needs. The role builds trusting relationships with members, anticipates their needs, and provides relevant benefit information and self-service resources. It also handles a range of operational tasks involving claims, referrals, complaints, grievances, appeals, pre-authorizations, provider credentialing questions, litigation-related document requests, audits, and financial data maintenance. The position is hybrid, with three onsite days each week—Tuesday through Thursday—in Franklin, Tennessee.

Requirements

High school diploma.
Ability to demonstrate empathy and compassion.
Experience in a production environment.
Work onsite in Franklin, Tennessee, three days per week, Tuesday through Thursday.

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 and advocating for their health.
Take accountability for understanding member needs and building trusting, caring relationships.
Anticipate customer needs and provide relevant information, including plan and benefit details and member 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, member and provider complaints, grievances, and appeals through the target system.
Educate providers about self-service options and assist with credentialing and re-credentialing issues.
Respond to litigation-related requests from Aetna’s Law Document Center and handle extensive file reviews.
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 requests for appeals and pre-authorizations 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.