Answers questions and resolves issues based on phone calls/letters from members, providers, and plan sponsors. Triages resulting rework to appropriate staff. Provide excellent customer services for high volume in bound provider calls for the Claims Inquiry/Claims Research team. Extensive claims research on multiple platforms to assist providers with payment questions.
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 & assists providers on our self-service options. Assists providers with credentialing and re-credentialing and contracting questions and issues.
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.
Work Hours: 8am to 7pm EST or 8am to 7pm Central
The typical pay range for this role is:
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.
Familiarity with Microsoft Office products
High speed internet access (25 mbps)
Is your router located in a place where you could set up and work with a direct connection (NOT WI-FI) (ethernet cord directly from computer to router). We provide a 6 ½ foot long ethernet cord, if the distance is further, you will be required to provide your own ethernet cable
Claims and coding knowledge
High School diploma or GED equivalent.
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.