Customer Service Representative

Bring your heart to CVS Health. Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand - with heart at its center - our purpose sends a personal message that how we deliver our services is just as important as what we deliver.

Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.

Position Summary

• Answers questions and resolves issues based on phone calls/letters from providers. Triages resulting rework to appropriate staff.
• Provide excellent customer services for high volume inbound provider calls for the Individual and Family Plan Exchange team.
• Extensive claims research on multiple platforms to assist providers with payment questions.
• Provides the customer with related information to answer the unasked questions, e.g. additional plan details, benefit plan details, provider self-service tools, etc.
• Uses customer service threshold framework to make financial decisions to resolve provider issues.
• Explains provider's rights and responsibilities in accordance with contract.
• Processes claim referrals, new claim handoffs, nurse reviews, provider complaints, and provider grievance and appeals.
• Educates & assists providers on our self-service options. Assists providers with credentialing and re-credentialing and contracting questions and issues.
• Determines medical necessity, applicable coverage provisions and verifies member plan eligibility relating to incoming provider correspondence and internal referrals.
• Performs review of member and provider claim history to ensure accurate tracking of benefit maximums and/or coinsurance/deductible.
• Work Hours - Could be scheduled between the hours of 7am to 7pm local time

• Familiarity with Microsoft Office products
• Excellent computer skills using multiple screens and systems to achieve results
• Experience in highly transactional call center environment
• Excellent customer service and critical thinking
• This is a fully-remote position. Candidate must be able to work independently and be comfortable with virtual training and communication methods.
• Secure, private home office location where PHI/PII information is not visible or overheard by others.
• High speed internet access (25 mbps at the minimum) and consistent, reliable connection is required.
• Home office location must be set up with a direct connection to the router (Wi-Fi is not allowed). We provide a 6 ½ foot long ethernet cord, if the distance is further, you will be required to provide your own ethernet cable.