[Remote] Customer Service Representative - Bilingual

Note: The job is a remote job and is open to candidates in USA. CVS Health is the nation’s leading health solutions company, dedicated to transforming health care. They are seeking a Bilingual Customer Service Representative to handle customer inquiries and provide support to members, ensuring a positive service experience.

Responsibilities

• Engages, consults and educates members based upon the member’s unique needs, preferences and under‐standing 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-ser‐vice 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-ser‐vice options; Assists providers with credentialing and re-credentialing issues
• Responds to re‐quests 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

Skills

• 6 months of Customer Service experience
• Strong communication and empathy skills
• Ability to navigate multiple systems and tools
• Fluency in English and Spanish is required
• Knowledge of health plan benefits and regulatory requirements
• Prior experience in healthcare, insurance, or call center environments is highly valued

Benefits

• Affordable medical plan options
• 401(k) plan (including matching company contributions)
• Employee stock purchase plan
• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching
• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility

Company Overview