CVS Health

Call Center Representative

• Make an average of 50 outbound calls per hour placed by an automatic dialer system to offer, explain, and schedule a free in-home or virtual health evaluation with a provider
• Follow 20+ approved scripts, ensure members understand and are comfortable with the terms, and respond to rebuttals persuasively and with professional courtesy
• Present a positive, professional, and high energy approach to clients, health plan members, and team members
• Meet daily goals set by the department (i.e., 300-400 outbound dials per day, 24 appointments set per day, shift and attendance policy adherence, quality targets, etc.) in an office or remote environment
• Adjust, reschedule, and cancel appointments with both members and contracted providers, as requested
• Monitor performance results including appointments, calls, handle time, and productivity using designated reporting systems
• Report member complaints and escalations immediately to Member Engagement Managers
• Participate in peer side-by-side coaching as needed
• Follow HIPAA and other security and privacy guidelines when handling protected health information accessed during normal work activities

Outbound Call Center Representative

Manager

• Negotiates, executes, reviews, and analyzes contracts and/or handles dispute resolution and settlement negotiations with solo, small group, or local providers.
• Manages contract performance in support of network quality, availability, and financial goals and strategies.
• Recruits providers as needed to ensure attainment of network expansion goals, achieve regulatory and/or internal adequacy targets.
• Collaborates cross-functionally to contribute to provider compensation and pricing development activities and recommendations, submission of contractual information, and the review and analysis of reports as part of negotiation and reimbursement modeling activities.
• Provides Subject Matter Expert support for questions related to recruitment initiatives, contracting, provider issues/resolutions, related systems and information contained.
• Provides guidance and share expertise to others on the team.
• Responsible for identifying and making recommendations to manage cost issues and supporting cost saving initiatives and/or settlement activities.
• Provides network development, maintenance, and refinement activities and strategies in support of cross-market network management unit.
• Assists with the design, development, management, and or implementation of strategic network configurations, including integration activities.
• Optimizes interaction with assigned providers and internal business partners to manage relationships and ensure provider needs are met.
• Ensures resolution of escalated issues related to claims payment, contract interpretation and parameters, or accuracy of provider contract or demographic information.

Provider Contract Negotiation Manager – Pacific Northwest

Consultant

• Provides Plan Sponsors with benefit plan consulting services
• Ensures all plan contracts and certificates are completed accurately and in a timely fashion
• Executes both routine and non-routine business support tasks for the Benefit area under limited supervision
• Follows area protocols, standards, and policies to provide effective and timely support
• Prepares, reviews and/or edits employer certificates, contracts, and employee booklets according to pre-determined standards ensuring benefits are mapped accordingly
• Drafts all legislatively mandated booklets and contracts requested by plan sponsors
• Communicates any required revisions and or changes to avoid unintended liability in support of the plan
• Completes legislative comparisons and assists with state filing processes
• Takes direction to execute techniques, processes, and responsibilities.

Senior Plan Document Consultant

• Develops a proactive plan of care to address identified issues
• Collaborates with members, providers, and community organizations to address healthcare and social determinants needs
• Uses clinical tools and information/data review to evaluate member's needs and benefits
• Applies clinical judgment to incorporate strategies designed to reduce risk factors
• Conducts assessments that consider information from various sources, such as claims
• Utilizes motivational interviewing skills to engage members
• Presents cases at interdisciplinary case conferences

Case Manager, Registered Nurse – Field

• Applies advanced clinical judgement to facilitate appropriate member physical health and behavioral healthcare
• Implements strategy to assess and plan care, direct provider collaboration, and coordinate psychosocial wraparound services
• Instructs the application of available resources to produce optimal, cost-effective outcomes

Clinical Case Manager, BH Field

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