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Appeals Processing Senior Representative

Job typeFull Time
CountryUnited States
Remote, Work From Home, United States

This role is WAH/Flex which allows most work to be performed at home. Employees must be fully vaccinated if they choose to come onsite.

Conducts detailed appeal investigation of all supporting documents and systems to determine if the appeal should be upheld or overturned based on all available facts. Proactively communicated with appellants, leadership team, providers and the original case manager to resolve investigation issues, resolve issues and communicate decisions/rationale for denial/approval.
  • Retrieve assigned cases from queue and based on analysis of issues determine appropriate classification
  • Validate all assigned cases; review appeal documents, correct appeal types, time frames and what is being appeals
  • Assign priority and internal due date based on various regulations which dictate the compliance time frames. This is a key step as incorrect classification will result in non-compliant cases
  • Independently conduct thorough review of all new member and provider correspondence by analyzing all the issues presented to determine appropriate classification
  • Employee is responsible for tracking internal due dates and time frames so that the Compliance time frames are met
  • Classify document all actions taken during review for auditing and reporting purposes
  • Monitor daily reports, as well as make necessary follow-up calls to internal and external entities to all information is received or before the applicable time frame
  • Assist the Manager/Supervisor in identifying root cause issues related to appeals
  • Regular attendance is an essential function of the job. Performs other duties as assigned or required
  • Requires the ability to consistently apply appropriate administrative and regulatory criteria for reviewing and making decisions on all non-clinical appeals and validating the accuracy of all received information
  • Requires effective communication abilities (written and verbal) when documenting actions and communications with Members, Providers, Medical Director and appeals leadership.
  • The role works closely with the multiple other roles and requires the ability to communicate status variances
  • Responsible for maintaining and prioritizing work load to support appeal timeliness and communicate risks, concerns or opportunities to leadership related to their work load

  • High school graduate minimum or GED required
  • LPN Preferred
  • 3 years' experience in Medicare Part C related to Appeals, Claims or Grievances required
  • Familiarity with state and federal regulations, medical terminology and coding.
  • Working knowledge of Medicare Advantage appeal regulations
  • Working knowledge of Explanation of Coverage
  • Strong written and verbal communications skills
  • Proven ability to analyze detailed information
  • Systems: FileBound, HCiCMS, QCare, Provider Link, One View, QNXT, CCMS, PARC & OnBase, Medhoc

  • Dealing with Ambiguity
  • Priority Setting
  • Learning and Applying Quickly
  • Problem Solving
  • Perseverance

This role is Flex/WFH which allows most work to be performed at home or on occasion at a Cigna office location. Employees must be fully vaccinated if they choose to come onsite.

This position is not eligible to be performed in Colorado.

About Cigna

Cigna Corporation exists to improve lives. We are a global health service company dedicated to improving the health, well-being and peace of mind of those we serve. Together, with colleagues around the world, we aspire to transform health services, making them more affordable and accessible to millions. Through our unmatched expertise, bold action, fresh ideas and an unwavering commitment to patient-centered care, we are a force of health services innovation. When you work with us, or one of our subsidiaries, you'll enjoy meaningful career experiences that enrich people's lives. What difference will you make?

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 require reasonable accommodation in completing the online application process, please email: SeeYourself@cigna.com for support. Do not email SeeYourself@cigna.com for an update on your application or to provide your resume as you will not receive a response.
Employer828 Newquest LLC