Evernorth CareNav + Care Guide - Evernorth Health Services - Remote

 This position supports a resolute team for our clients Evernorth app & Express Scripts Pharmacy inquiries with expanded responsibilities in proactively educating on and recommending a multitude of Evernorth programs and services. The team consists of highly analytical, technical-minded Customer Service experts with depth of knowledge in resolving and navigating within a multifaceted health care setting. Candidates must have a proven track record in solutioning complex claim issues, identifying & navigating critical health conditions, and diligence in every interaction ensuring an accurate and firm focus on timely resolution. Ideal candidates must possess the ability to listen intently with a focus first on resolution to the reason for their outreach followed by recommendation of pharmacy benefit and vendor offerings that will achieve optimal emotional, financial, and physical health outcomes. This position must think and perform more critically & creatively, leveraging their call-center experience with a keen problem-solving skill to take their service in this role to the next level. The ability to operate in the absence of precise work instruction is critical for success.  

This position will have the following responsibilities related to supporting the pharmacy & Evernorth app needs of our members: 

• Will provide the highest level of service on inbound member interactions with some candidates also providing digital chat support to customers. 

• Assists customer with the Evernorth app including but not limited to: 1) Helping download, register, and log into the app; 2) Inform of all app features and highlight navigation steps to find vendor offerings; 3) Educate on Wellness Rewards and value propositions; 4) Troubleshoot app & provide follow-up on tickets submitted for resolution. 

• Supports member inquiries and needs for their Express Scripts mail order account including but not limited to: 1) Eligibility; 2) Benefit quotes; 3) Complex claim resolution or education; 4) Cost savings strategies; 5) Advanced support with prior authorizations; Advanced support on claims rejections & overrides. 

• Required to have a strong and thorough understanding of the full suite of Medical & Pharmacy benefits and external vendor offerings. 

• Confidently partner with other departments to ensure all members’ needs met to achieve resolution and recommendations for next steps in their healthcare journey. 

• Listens to understand members unique needs, while seeking more information through probing questions with the goal of offering vendor programs and services that apply to their past, current or future needs. 

• Investigates and resolves escalations, barriers to care, and complaints obtaining necessary information from policies and procedures. When knowledge base documents are not available to guide next steps, must be able to determine the best solution or option autonomously and accurately for customer. 

• Proactively offer outreaches to pharmacy, doctor or vendors as needed to bring next steps into action or resolution removing effort from the member. 

• Takes ownership and provides timely follow-up on any takeaway from member interactions. i.e., Evernorth app tickets, prior authorizations pending, findings from claim discrepancies, etc. 

• May serve as primary contact and liaison between customers, health plans, service centers, and/or functional areas.  

• Thorough technical knowledge of products and excellent communication skills.  

• Be a champion of change and adapt well to frequent adjustments to procedures. 

• Must be highly coachable and open to feedback to improve member experience driving a consistently accurate quality of service.  

QUALIFICATIONS:  

• High School diploma, GED or higher required and/or 2+ years’ work experience in customer service field.

• Required 1+ years call experience in US Commercial Pharmacy Call Operations background; specifically PBM Commercial trained.

• Ability to actively listen to understand current needs and complexities while identifying the next steps & potential future needs.

• Excellent written and verbal interpersonal communication skills.  

• Adept with KnowledgeXchange & initiative-taking resource utilization.

• Confidence with technology, innovational progress, and ability to toggle three or more systems.

• Creative problem-solving and analytical skills with self-awareness of time to resolution. 

• Proven record of working independently to manage day in a fast-paced, quality driven environment. 

• Proficiency in Outlook and WebEx. 

PERFORMANCE REQUIREMENTS: 

• Consistently strong KPI scores over the last 12 months must be meeting or exceeding current targets. 

• Quality: ≥95%  

• Resolution: ≥90%  

• CSAT: ≥4.75 

• Caller Effort: ≥85%