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

This role is fully remote. Must live in the following time zones, EST or CST

• Answers questions and resolves issues based on phone calls/letters from members, providers, and plan sponsors. Triages resulting rework to appropriate staff. Provide excellent customer services for high volume in bound provider calls for the Claims Inquiry/Claims Research 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, 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 & assists providers on our self-service options. Assists providers with credentialing and re-credentialing and contracting questions and issues.
• 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.
• Work Hours 7am to 7pm local time

• Familiarity with Microsoft Office products such as Word, Teams, Excel
• Ability to maneuver through multiple applications to gather information while on a call
• Experience in highly transactional call center environment
• Excellent customer service and critical thinking
• Must secure high speed internet access (100 mbps or higher) and consistent, stable connection. A speed test will be required to proceed with an interview.
• Work location must be set up with a direct connection to the router (NOT Wi-Fi). We provide a 6 ½ foot long ethernet cord, if the distance is further, you will be required to provide your own ethernet cable.

• Healthcare background

• High School diploma or GED equivalent.