This role is responsible for reviewing and resolving medical claims appeals submitted by customers, clients, and healthcare professionals. The Appeals Processing Sr. Representative researches claim decisions against established payment guidelines, internal procedures, and regulatory requirements to determine whether claims were processed correctly or require adjustment.

Responsibilities

• Review incoming Appeals from Customers, Clients and HealthCare Professionals
• Research item being appealed against Standard Operating Claim Payment Procedures and/or State and Federal Regulations in IComply, and Benefit Access
• Determine if the claim issue in question was paid correctly or needs an adjustment
• Adjust overturned appeals or appropriately route the appeal for adjustment
• Manage personal inventory and aging by use of daily reports provided
• Prepare and route appeals requiring clinical review to the Clinical Appeals Team
• Create and issue documentation explaining appeal decision

Qualifications

• High School Diploma or equivalent required
• Proclaim/Facets systems, OneView and iView knowledge is preferred
• Able to manage multiple tasks and work under pressure in a fast paced environment
• Excellent verbal and written communication skills
• Strong attention to detail and the ability to work in multiple systems concurrently
• Strong organization and time management skills; effectively adapts to multiple and/or competing priorities
• Process improvement skills; ability to assess trends, processes and barriers to drive positive outcomes for resolutions

About The Cigna Group

Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or related medical conditions including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national origin, ancestry, marital or familial status, genetic information, status with regard to public assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws.

If you need a reasonable accommodation to complete the online application process, please email seeyourself@thecignagroup.com for assistance.  Please note that this email inbox is dedicated to accommodation requests only and cannot provide application updates or accept resumes.

The Cigna Group has a tobacco-free policy and reserves the right not to hire tobacco/nicotine users in states where that is legally permissible. Candidates in such states who use tobacco/nicotine will not be considered for employment unless they enter a qualifying smoking cessation program prior to the start of their employment. These states include: Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Georgia, Hawaii, Idaho, Iowa, Kansas, Maryland, Massachusetts, Michigan, Nebraska, Ohio, Pennsylvania, Texas, Utah, Vermont, and Washington State.

Qualified applicants with criminal histories will be considered for employment in a manner consistent with all federal, state and local ordinances.

High school diploma or equivalent required; Proclaim/Facets, OneView, iView preferred; strong communication, attention to detail, organization, and process improvement skills; ability to work in multiple systems concurrently.

Key Responsibilities

• reviewing appeals
• researching claims
• documenting decisions

Skills & Tools

IComply, Benefit Access, Proclaim, Facets, OneView, iView

Job Details

• Category: Healthcare Services - Allied Health
• Seniority: Mid Level
• Commitment: Full Time
• Workplace: Remote — New Hampshire, United States
• Languages: English

About The Cigna Group

A global health service company dedicated to improving the health and vitality of those it serves. — Industry: Healthcare