CVS Health is dedicated to building a world of health around every individual, and they are seeking a Customer Service New Business Operations professional to enhance member engagement. This role involves creating emotional connections with members, understanding their needs, and providing relevant information to ensure a compassionate health experience.

Responsibilities

• 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

Skills

• 3 days onsite Tuesday-Thursday in Franklin, TN
• 1-3 years Customer Service experiences in a transaction based environment such as a call center or retail location preferred
• Demonstrating ability to be empathetic and compassionate
• Experience in a production environment
• High School Diploma
• Proficient in Excel
• SQL experience a plus
• Insurance Knowledge - Plus

Benefits

• Medical, dental, and vision coverage
• Paid time off
• Retirement savings options
• Wellness programs
• Other resources, based on eligibility

Company Overview