Inbound/Outbound Queue Associate - Must live in Eastern Time Zone

At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day. Shift: Monday - Friday, 10:00 AM to 7:00 PM EST Position Summary Supports comprehensive coordination of medical services including intake, screening and referrals to Aetna Medical Services Programs.

Responsibilities

• Promotes/supports quality effectiveness of Healthcare Services. Performs intake of calls from members or providers regarding services via telephone, fax, EDI.
• Utilizes eTUMS and other Aetna system to build, research and enter member information.
• Screens requests for appropriate referral to medical services staff. Approve services that do not require a medical review in accordance with the benefit plan.
• Performs non-medical research including eligibility verification, COB, and benefits verification.
• Maintains accurate and complete documentation of required information that meets risk management, regulatory, and accreditation requirements.
• Promotes communication, both internally and externally to enhance effectiveness of medical management services (e.g., claim administrators, Plan
• Sponsors, and third party payers as well as member, family, and health care team members respectively).
• Protects the confidentiality of member information and adheres to company policies regarding confidentiality
• Communicate with Aetna Case Managers, when processing transactions for members active in this Program
• Supports the administration of the precertification process in compliance with various laws and regulations, URAQ and/or NCQA standards, where applicable, while adhering to company policy and procedures.
• Places outbound calls to providers under the direction of Medical
• Management Nurses to obtain clinical information for approval of medical authorizations.
• Uses Aetna Systems such as QNXT, ProFAX, ProPAT, and Milliman Criteria.
• Communicates with Aetna Nurses and Medical Directors, when processing transactions for members active in this Program.
• Sedentary work involving significant periods of sitting, talking, hearing and keying.
• Work requires visual acuity to perform close inspection of written and computer generated documents as well as a PC monitor.
• Working environment includes typical office conditions.

Required Qualifications

• 2-4 years experience as a medical assistant, office assistant or other clinical experience.
• Call Center experience is required.
• Must Reside in the Eastern time zone.

Education High School diploma or equivalent GED Anticipated Weekly Hours 40 Time Type Full time Pay Range The Typical Pay Range For This Role Is $17.00 - $28.46 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great Benefits For Great People We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an 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.

For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 09/13/2025 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. Apply tot his job Apply To this Job