Provider Claims Customer Service Representative - Two Chicks With A Side Hustle

Employer: CVS Health

Job Description:

This position also includes a $1,000 sign on bonus to be paid after 30 days of training (Bonuses are only applicable to external candidates in specific positions, locations, and business groups. Applicable roles have the bonus language in the job posting).

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.

Required Qualifications

High school diploma or GED equivalent
Familiarity with Microsoft Office products
High speed internet access (25 mbps)

COVID Requirements

COVID-19 Vaccination Requirement
CVS Health requires certain 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, religious belief, or other legally recognized reasons that prevents them from being 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 or apply for a reasonable accommodation within the first 10 days of your employment. Please note that in some states and roles, you may be required to provide proof of full vaccination or an approved reasonable accommodation before you can begin to actively work.

Preferred Qualifications

Familiarity with medical claims billing and coding (CPT/HCPCS/Revenue/Diagnosis)
Familiarity or experience with claims processing, provider reimbursement methodologies