Customer Service Representative - Bilingual (Spanish)

CVS Health is dedicated to building a world of health around every individual, creating a connected and compassionate health experience. The Customer Service Representative will engage with members to address inquiries, resolve issues, and guide them through their health plans while fostering a trusting relationship.

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 thresh‐old 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 in‐coming 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 in‐bound Brokerage calls to provide application status, contract and appointment status

Requirements:

• Must be fluent in English and Spanish
• Strong communication and empathy skills
• Ability to navigate multiple systems and tools
• Knowledge of health plan benefits and regulatory requirements
• High School Diploma or GED
• Prior experience in healthcare, insurance, or call center environments is highly valued
• A location in the Eastern Time Zone is preferred