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Company Name : CVS Health
Location : California
Position : Customer Service Representative – HCB Ops
Job Description : Customer Service is the important first-line of contact with customers,
setting the tone for how members, doctors and plan sponsor groups view
our company. It provides members with the right information at the right
time to help them make better decisions about their health and health care.
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.
Customer
Required Qualifications
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.
COVID Requirements
CVS Health requires its 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, or religious belief that prevents them from being vaccinated.
If you are 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 within the first 10 days of your employment. For the two COVID-19 shot regimen, you will be required to provide proof of your second COVID-19 shot within the first 45 days of your employment. In some states and roles, you may be required to provide proof of full vaccination before you can begin to actively work. Failure to provide timely proof of your COVID-19 vaccination status will result in the termination of your employment with CVS Health.
If you are unable to be fully vaccinated due to disability, medical condition, or religious belief, you will be required to apply for a reasonable accommodation within the first 10 days of your employment in order to remain employed with CVS Health. As a part of this process, you will be required to provide information or documentation about the reason you cannot be vaccinated. In some states and roles, you may be required to have an approved reasonable accommodation before you can begin to actively work. If your request for an accommodation is not approved, then your employment may be terminated.
Preferred Qualifications
Call Center Experience
Able to Multi-Task
Microsoft Office Skills
Education
High School or GED equivalent.
Business Overview
At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.
We are committed to maintaining a diverse and inclusive workplace. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.
This post is listed Under California jobs
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