Customer Service Representative - Bilingual - HCB Ops

CVS Health Customer Service Representative

At CVS Health, we're building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation's leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day. This position is designated for bilingual candidates. Fluency in English and Spanish is required.

Position Summary : 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.

Responsibilities :

• Engages, consults and educates members based upon the member's unique needs, preferences and understanding of Aetna plans, tools and resources to help guide the 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.
• As a call center inbound representative you will be responsible for taking inbound Brokerage calls to provide application status, contract and appointment status.
• In addition you will review commission inquires, data entry, processing of Medicare contracts, appointments and verification of certification for external producers / agents to be eligible to market Medicare plans. May supplement the background check review and documentation process as well.

Required Qualifications :

Preferred Qualifications :

Education :

Anticipated Weekly Hours : 40

Time Type : Full time

Pay Range : The typical pay range for this role is : $17.00 - $34.15

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

Great benefits for great people. We take pride in our comprehensive and competitive mix of pay and benefits investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include :

For more information, visit https : / / jobs.cvshealth.com / us / en / benefits

We anticipate the application window for this opening will close on : 12 / 20 / 2025

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. We are an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex / gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.