Customer Service Representative
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About The Position
At CVS Health, we are dedicated to bringing our heart to every moment of your health. This commitment drives our mission to provide enhanced human-centric health care in a rapidly changing world. Our Heart At Work Behaviors reflect this purpose, empowering every employee to play a vital role in transforming our culture and accelerating our ability to innovate and deliver solutions that make health care more personal, convenient, and affordable. The Customer Service Representative position is fully remote, requiring candidates to reside in the EST, PST, or CST time zones. In this role, you will be responsible for answering questions and resolving issues from members, providers, and plan sponsors through phone calls and letters. You will triage any resulting rework to the appropriate staff and provide excellent customer service for high-volume inbound provider calls related to claims inquiries and research. This position involves extensive claims research across multiple platforms to assist providers with payment questions. You will also provide customers with related information to address unasked questions, such as additional plan details and member self-service tools. Utilizing a customer service threshold framework, you will make financial decisions to resolve member issues and explain members' rights and responsibilities in accordance with their contracts. Additionally, you will process claim referrals, new claim handoffs, nurse reviews, and complaints from both members and providers, as well as grievances and appeals. Your role will include educating and assisting providers on self-service options, as well as addressing credentialing and re-credentialing questions. You will compile claim data for customer audits and determine medical necessity, applicable coverage provisions, and verify member plan eligibility based on incoming correspondence and internal referrals. The work hours for this position are from 7 AM to 7 PM local time.
