Customer Service Representative (Bilingual Spanish/...

Job DescriptionCustomer Service Representative is the face of Aetna and impactsmembers' service experience by manner of how customer service inquiries and problems via telephone, internet or written correspondence are handled. Customer inquiries are of basic and at times complex nature.Engages, consults and educates members based upon the member's unique needs, preferences and understanding of Aetna plans, tools andresources to help guide the members along a clear path to care.Pay RangeThe typical pay range for this role is:Minimum: 17.02Maximum: 27.16Please 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 QualificationsBilingual English/SpanishCustomer Service experiences in a transaction based environment such as a call center or retail location preferred, demonstrating ability to beempathetic and compassionate.Experience in a production environment.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, providersand plan sponsors. The CSR guides the member through their members plan of benefits, Aetna policy and procedures as well as having knowledgeof resources to comply with any regulatory guidelines.Creates an emotional connection with our members by understanding andengaging the member to the fullest to champion for our members' besthealth.Taking accountability to fully understand the member's needs by building atrusting and caring relationship with the member.Anticipates customer needs. Provides the customer with related informationto answer the unasked questions, e.g. additional plan details, benefit plandetails, member self-service tools, etc.Uses customer service threshold framework to make financial decisions toresolve 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 targetsystem.Educates providers on our self-service options; Assists providers withcredentialing and re-credentialing issues.Responds to requests received from Aetna's Law Document Centerregarding litigation; lawsuitsHandles extensive file review requests. Assists in preparation of complainttrend reports. Assists in compiling claim data for customer audits.Determines medical necessity, applicable coverage provisions and verifiesmember plan eligibility relating to incoming correspondence and internalreferrals.Handles incoming requests for appeals and pre-authorizations not handledby Clinical Claim Management.Performs review of member claim history to ensure accurate tracking ofbenefit maximums and/or coinsurance/deductible. Performs financial datamaintenance as necessary.Uses applicable system tools and resources to produce quality letters andspreadsheets in response to inquiries received.COVID RequirementsCOVID-19 Vaccination RequirementCVS 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 QualificationsAbility to multi-task to accomplish workload efficiently.Understanding of medical terminology.Oral and written communication skills.Ability to maintain accuracy and production standards.Negotiation skills.Technical skills.Problem solving skills.Attention to detail and accuracy.Analytical skills.EducationHigh School or GED equivalent.Business OverviewBring your heart to CVS HealthEvery 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.

Created: 2025-10-04