Member Services 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.

Responsible for increasing member and provider satisfaction, retention, and growth by efficiently delivering competitive services to members and providers through a fully integrated organization staffed by knowledgeable, customer-focused professionals supported by exemplary technologies and processes. 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 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.

• Strong technical knowledge of the function being trained.

Required Qualifications

Candidate must Reside in Oklahoma
• Customer Service experiences in a transaction-based environment such as a call center.

• Experience in a production environment.

Preferred Qualifications

·Medicaid or health care experience.

Education

• High School or GED equivalent.

Pay Range

The typical pay range for this role is:

$17.00 - $25.65

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 carin