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

　　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• 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 caring for our colleagues and our communities. The Company offers a full range of medical, dental, and vision benefits. Eligible employees may enroll in the Company’s 401(k) retirement savings plan, and an Employee Stock Purchase Plan is also available for eligible employees. The Company provides a fully-paid term life insurance plan to eligible employees, and short-term and long term disability benefits. CVS Health also offers numerous well-being programs, education assistance, free development courses, a CVS store discount, and discount programs with participating partners. As for time off, Company employees enjoy Paid Time Off (“PTO”) or vacation pay, as well as paid holidays throughout the calendar year. Number of paid holidays, sick time and other time off are provided consistent with relevant state law and Company policies. For more detailed information on available benefits, please visit jobs.CVSHealth.com/benefits

　　CVS Health requires certain colleagues to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, religious belief, or other legally recognized reasons that prevents them from being vaccinated.

　　You are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status or apply for a reasonable accommodation within the first 10 days of your employment. Please note that in some states and roles, you may be required to provide proof of full vaccination or an approved reasonable accommodation before you can begin to actively work.

　　CVS Health is committed to recruiting, hiring, developing, advancing, and retaining individuals with disabilities. As such, we strive to provide equal access to the benefits and privileges of employment, including the provision of a reasonable accommodation to perform essential job functions. CVS Health can provide a request for a reasonable accommodation, including a qualified interpreter, written information in other formats, translation or other services through [email protected] If you have a speech or hearing disability, please call 7-1-1 to utilize Telecommunications Relay Services (TRS). We will make every effort to respond to your request within 48 business hours and do everything we can to work towards a solution.