To increase member satisfaction, retention, and growth by efficiently delivering competitive services to members and providers through a fully-integrated organization staffed by knowledgeable, customer-focused professionals. Handles Individual and Family Plan (IFP) Exchange provider service inquiries and problems via telephone, internet or written correspondence. Provider inquiries can be of basic and routine nature, or can be more complex with extensive research needed to resolve issues.

Pay Range
The typical pay range for this role is:
Minimum: 17.00
Maximum: 27.16

Please keep in mind that this range represents the pay range for all positions in the job grade within which this position falls. The actual salary offer will take into account a wide range of factors, including location.

Required Qualifications

• Answers questions and resolves issues based on phone calls/letters from providers and plan sponsors. Triages resulting rework to appropriate staff.
• Documents and tracks contacts with members, providers and plan sponsors.
• Explains provider's rights and responsibilities in accordance with contract.
• Processes claim referrals, new claim handoffs, nurse reviews, provider complaints, and provider grievance and appeals 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 provider correspondence and internal referrals.
• Handles incoming requests for appeals and pre-authorizations not handled by Clinical Claim Management.
• Performs review of member and provider 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.

Preferred Qualifications

• Passion for exceptional customer service, taking ownership of issues to full resolution
• Identification of issues and trending through provider feedback from calls/correspondence received
• Experience in a production environment
• Customer Service experiences in a transaction based environment, such as a call center or retail location preferred
• Continuous process improvement / project management mindset
• Ability to multi-task to accomplish workload efficiently
• Analytical and independent critical thinking skills
• Ability to maintain accuracy and production standards
• Advanced Technical skills (i.e. MS Office, especially Word and Excel, typing at 50+ wpm)
• Oral and written communication skills
• Problem solving skills
• Attention to detail & accuracy

Education
High School diploma, G.E.D. or equivalent experience

Business Overview
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. We strive to promote and sustain a culture of diversity, inclusion and belonging every day. CVS Health is an affirmative action employer, and is an equal opportunity employer, as are the physician-owned businesses for which CVS Health provides management services. 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. 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.