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, timeframes and what is being appeals
Assign priority and internal due date based on various regulations which dictate the compliance timeframes. 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 timeframes so that the Compliance timeframes 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 timeframe
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 Diploma required
At least 3 Years' experience Medicare Part C related to Appeals, Claims or Grievances preferred
Working knowledge of Medicare Advantage appeal regulations
Working knowledge of CHS Explanation of Coverage
Strong written and verbal communications skills
Proven ability to analyze detailed information
Systems: CCMS, PARC, FileBound and OnBase
Schedule: Monday-Friday 8:00AM-5:00PM
ROTATIONAL WEEKENDS REQUIRED
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.