Medicaid Provider Customer Service Representative - CVS : Job Details

Answer questions and resolves issues based on phone calls/letters from providers. Triage resulting rework to appropriate staff. Provide excellent customer services for high volume inbound provider calls for the Claims Inquiry/ Claims Research Medicaid team. Extensive claims research on multiple platforms to assist providers with payment questions. Educate provider with related information to answer the unasked questions, e.g., additional plan details, benefit plan details, provider self-service tools, etc. Use customer service threshold framework to make financial decisions to resolve provider issues. Explain provider's rights and responsibilities in accordance with contract. Process claim referrals, new claim handoffs, nurse reviews, provider complaints, grievance and appeals via target system. Assists providers with credentialing/re-credentialing and contracting questions and issues. Assist in compiling claim data for audits. Determines medical necessity, applicable coverage provisio...Customer Service Representative, Customer Service, Representative, Retail