Inbound Outbound Queue Associate – Must reside in EST
CVS Health, Richmond, VA, United States
Shift
Monday‑Friday, 8:00 AM–5:00 PM EST
Position Summary Supports comprehensive coordination of medical services including intake, screening, and referrals to Aetna Medical Services Programs.
Responsibilities
Promotes and supports the quality and effectiveness of Healthcare Services. Performs intake of calls from members or providers regarding services via telephone, fax, or EDI.
Utilizes eTUMS and other Aetna systems to build, research, and enter member information.
Screens requests for appropriate referral to medical services staff; approves services that do not require a medical review in accordance with the benefit plan.
Performs non‑medical research including eligibility verification, coordination of benefits (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 the effectiveness of medical management services (e.g., claim administrators, plan sponsors, third‑party payers, member families, and health‑care team members).
Protects the confidentiality of member information and adheres to company policies regarding confidentiality.
Communicates with Aetna Case Managers when processing transactions for members active in this program.
Supports the administration of the pre‑certification 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.
Works in a sedentary environment, involving significant periods of sitting, talking, hearing, and keying.
Requires visual acuity to perform close inspection of written and computer‑generated documents and to use a PC monitor.
Works in a typical office environment.
Required Qualifications
2–4 years of experience as a medical assistant, office assistant, or other clinical experience.
Must reside in the Eastern Standard Time Zone.
Preferred Qualifications
Microsoft Office skills.
Call center experience.
Customer service skills.
Education
High school diploma or equivalent GED.
Pay Range Typical pay range: $17.00 – $28.46 per hour, based on experience, education, geography, and other factors. This position is eligible for a CVS Health bonus, commission, or short‑term incentive program in addition to base pay.
Benefits This full‑time position is eligible for a comprehensive benefits package designed to support physical, emotional, and financial well‑being of colleagues and their families, including medical, dental, vision coverage, paid time off, retirement savings options, wellness programs, and other resources based on eligibility.
Schedule Anticipated weekly hours: 40. Time type: Full time.
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws.
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Position Summary Supports comprehensive coordination of medical services including intake, screening, and referrals to Aetna Medical Services Programs.
Responsibilities
Promotes and supports the quality and effectiveness of Healthcare Services. Performs intake of calls from members or providers regarding services via telephone, fax, or EDI.
Utilizes eTUMS and other Aetna systems to build, research, and enter member information.
Screens requests for appropriate referral to medical services staff; approves services that do not require a medical review in accordance with the benefit plan.
Performs non‑medical research including eligibility verification, coordination of benefits (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 the effectiveness of medical management services (e.g., claim administrators, plan sponsors, third‑party payers, member families, and health‑care team members).
Protects the confidentiality of member information and adheres to company policies regarding confidentiality.
Communicates with Aetna Case Managers when processing transactions for members active in this program.
Supports the administration of the pre‑certification 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.
Works in a sedentary environment, involving significant periods of sitting, talking, hearing, and keying.
Requires visual acuity to perform close inspection of written and computer‑generated documents and to use a PC monitor.
Works in a typical office environment.
Required Qualifications
2–4 years of experience as a medical assistant, office assistant, or other clinical experience.
Must reside in the Eastern Standard Time Zone.
Preferred Qualifications
Microsoft Office skills.
Call center experience.
Customer service skills.
Education
High school diploma or equivalent GED.
Pay Range Typical pay range: $17.00 – $28.46 per hour, based on experience, education, geography, and other factors. This position is eligible for a CVS Health bonus, commission, or short‑term incentive program in addition to base pay.
Benefits This full‑time position is eligible for a comprehensive benefits package designed to support physical, emotional, and financial well‑being of colleagues and their families, including medical, dental, vision coverage, paid time off, retirement savings options, wellness programs, and other resources based on eligibility.
Schedule Anticipated weekly hours: 40. Time type: Full time.
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws.
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