About CVS Health – A Purpose‑Driven Leader in Health Care
At CVS Health, our single, clear purpose is “Bringing our heart to every moment of your health.” This purpose fuels a culture where every employee feels empowered to make health care more personal, convenient, and affordable for the millions of people we serve every day. From our nationwide network of pharmacies and walk‑in clinics to our expansive health‑plan services, CVS Health is redefining what it means to be a caring, innovative health‑care partner. Our brand is built on a foundation of Heart at Work behaviors that encourage collaboration, curiosity, humility, and a relentless focus on the patient experience.
Joining our team means becoming part of an organization that invests in your professional growth, celebrates diverse perspectives, and supports a healthy work‑life balance. Whether you are working from the comfort of your home office or collaborating with colleagues across the country, you will be part of a mission‑driven community that values integrity, respect, and a genuine desire to improve health outcomes.
Position Overview – Why This Role Is Critical to Our Mission
The Remote Inbound & Outbound Healthcare Queue Associate plays a pivotal role in the delivery of high‑quality, member‑centric services for Aetna Better Health, a CVS Health medical‑plan brand. As the primary point of contact for members, providers, and internal stakeholders, you will ensure that each interaction is handled with empathy, accuracy, and efficiency. Your work directly supports the coordination of medical services, from intake and eligibility verification to pre‑authorization and referral management, helping members navigate complex health‑care pathways with confidence.
This full‑time, work‑from‑home position offers flexibility, autonomy, and a competitive compensation package. You will operate within a supportive, technology‑enabled environment that values continuous improvement and professional development.
Key Responsibilities – What You’ll Be Doing Every Day
- Member & Provider Intake: Answer inbound calls, fax, and electronic data interchange (EDI) requests from members and health‑care providers, capturing accurate information in Aetna’s systems.
- Eligibility & Benefits Verification: Conduct non‑medical research to confirm member eligibility, coordination of benefits (COB), and plan coverage details, ensuring compliance with regulatory standards.
- Referral Screening & Authorization: Review requests, determine the appropriate level of medical review, and approve services that fall outside of pre‑authorization requirements.
- Pre‑Certification & Prior Authorization: Support the full pre‑certification lifecycle, including gathering clinical information, interacting with Aetna nurses and medical directors, and documenting decisions per NCQA and state regulations.
- Outbound Communication: Initiate outbound calls to providers to obtain missing clinical data, clarify authorization requirements, and convey approval or denial decisions.
- Documentation & Risk Management: Maintain thorough, accurate records that meet accreditation, risk‑management, and privacy standards; ensure all member data is protected in accordance with HIPAA.
- System Utilization: Navigate Aetna’s proprietary platforms—including MedCompass, QNXT, ProFAX, and ProPAT—to enter, update, and retrieve member information efficiently.
- Collaboration & Communication: Liaise with claim administrators, plan sponsors, third‑party payers, and internal teams to resolve issues and enhance the overall effectiveness of medical management services.
- Performance Metrics & Quality Assurance: Monitor key performance indicators (KPIs) such as call handling time, accuracy rates, and member satisfaction scores, contributing to continuous improvement initiatives.
- Adherence to Policies & Regulations: Stay current with federal, state, and industry regulations, ensuring all actions align with company policies, accreditation standards, and legal requirements.
Essential Qualifications – What You Must Bring to the Table
- 1‑2 years of experience in a medical‑assistant, office‑assistant, or similar clinical role, demonstrating familiarity with health‑care terminology and processes.
- High school diploma or GED; additional certifications (e.g., Certified Medical Assistant) are a plus.
- Residency in the state of Florida, with a reliable high‑speed internet connection and a suitable home office environment.
- Proven ability to handle both inbound and outbound communications with professionalism, empathy, and accuracy.
- Strong written and verbal communication skills, including the ability to explain complex medical information in plain language.
- Excellent organizational skills, attention to detail, and the capacity to manage multiple tasks simultaneously while meeting tight deadlines.
- Basic proficiency with computer applications; experience with Aetna’s platforms (MedCompass, QNXT, ProFAX, ProPAT) or similar health‑plan systems is advantageous.
- Demonstrated commitment to confidentiality and data security, adhering strictly to HIPAA and CVS Health privacy policies.
Preferred Qualifications – Extras That Set You Apart
- Previous experience in a call‑center environment, particularly within health‑care, insurance, or member services.
- 1‑2 years of prior authorization or pre‑certification experience, showcasing an understanding of clinical documentation requirements.
- Familiarity with NCQA standards, state‑specific health‑plan regulations, and other compliance frameworks.
- Advanced customer‑service training or certifications (e.g., Certified Customer Service Professional).
- Experience working with electronic health records (EHR) or other health‑information systems.
- Demonstrated ability to thrive in a remote‑work setting, including self‑discipline, time‑management, and effective virtual collaboration.
Core Skills & Competencies – What Success Looks Like
- Empathy & Member‑Centric Mindset: Ability to listen actively, understand member needs, and provide compassionate support.
- Analytical Thinking: Skill in interpreting clinical data, spotting inconsistencies, and making informed authorization decisions.
- Problem‑Solving: Comfortable navigating complex scenarios, escalating when necessary, and delivering timely resolutions.
- Technology Savvy: Quick learner of new software platforms, adept at data entry, and capable of troubleshooting basic technical issues.
- Communication Excellence: Clear, concise, and professional verbal and written interactions with a diverse set of stakeholders.
- Regulatory Awareness: Understanding of HIPAA, state privacy laws, and industry accreditation standards.
- Team Collaboration: Ability to work cross‑functionally with nurses, medical directors, and internal support teams, sharing knowledge and best practices.
- Adaptability: Comfortable with evolving processes, policy updates, and changes in the health‑care landscape.
Career Development & Learning Opportunities – Grow With Us
CVS Health is dedicated to helping you build a long‑lasting, rewarding career. As a Remote Inbound & Outbound Queue Associate, you will have access to a robust suite of development resources:
- Professional Training: Free enrollment in internal courses covering health‑plan operations, customer‑service excellence, and compliance.
- Certification Support: Financial assistance for industry‑recognized certifications such as Certified Professional in Healthcare Quality (CPHQ) or Certified Medical Reimbursement Specialist (CMRS).
- Mentorship Programs: Pairing with seasoned medical‑management leaders for guidance, skill‑building, and career planning.
- Career Pathways: Clear advancement tracks toward roles like Senior Authorization Specialist, Team Lead, Operations Supervisor, or Health‑Plan Analyst.
- Cross‑Functional Exposure: Opportunities to collaborate with other CVS Health divisions, broadening your understanding of the integrated health‑care ecosystem.
- Continuous Feedback: Regular performance reviews, coaching sessions, and goal‑setting conversations to help you reach your potential.
Compensation, Benefits & Perks – What You’ll Receive
In addition to a competitive hourly wage ranging from $17.00 to $25.65 (depending on experience, education, and location), you will be eligible for a comprehensive benefits package designed to support you and your family:
- Health Coverage: Medical, dental, and vision plans with a variety of options to fit different needs.
- Retirement Savings: Enrollment in CVS Health’s 401(k) plan with company matching contributions.
- Employee Stock Purchase Plan (ESPP): Opportunity to purchase CVS Health stock at a discounted rate.
- Life & Disability Insurance: Fully‑paid term life coverage, short‑term and long‑term disability protection.
- Well‑Being Programs: Access to mental‑health resources, fitness incentives, and wellness challenges.
- Education Assistance: Tuition reimbursement and free development courses to help you acquire new skills.
- Retail Discounts: Employee discount at CVS Pharmacy locations nationwide.
- Paid Time Off (PTO) & Holidays: Generous vacation accruals, paid holidays, and sick leave in line with state regulations.
- Performance Incentives: Eligibility for bonuses, commissions, or short‑term incentive programs based on individual and team performance.
Work Environment & Company Culture – A Remote Setting That Feels Connected
Despite being a remote role, you will never feel isolated. Our virtual collaboration tools, regular team huddles, and inclusive communication channels keep you connected to the larger CVS Health community. Key cultural highlights include:
- Heart‑Centered Values: A culture that celebrates authenticity, humility, accountability, and respect.
- Flexibility & Autonomy: Design a work schedule that balances professional responsibilities with personal priorities.
- Diversity & Inclusion: Commitment to a workplace where all voices are heard and diverse perspectives drive innovation.
- Recognition Programs: Regular acknowledgment of individual and team achievements through awards, spot bonuses, and internal shout‑outs.
- Sustainability Initiatives: Participation in CVS Health’s environmental stewardship programs that aim to reduce carbon footprint and promote community health.
- Community Impact: Opportunities to volunteer in local health‑care outreach programs, reinforcing our purpose of helping communities thrive.
How to Apply – Take the Next Step Toward a Meaningful Career
If you are ready to bring your heart, expertise, and enthusiasm to a role that truly makes a difference in people’s lives, we encourage you to apply today. Please submit your resume and a brief cover letter outlining your relevant experience, motivation for joining CVS Health, and how you embody our Heart at Work behaviors.
Application Deadline: October 29, 2024
CVS Health is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, protected veteran status, or disability status.
We look forward to welcoming you to a team that’s passionately committed to improving health care—one member at a time.
Apply Now