SUMMARY

Delivers straightforward administrative and/or other basic business services in Claims. Examines and processes paper claims and/or electronic claims. Determines whether to return, pend, deny or pay claims within policies. Determines steps necessary for adjudication. Settles claims with claimants in accordance with policy provisions. Compares claim application and/or provider statement with policy file and other records to evaluate completeness and validity of claim. Interacts with agents and claimants by mail or phone to correct claim form errors or omissions and to investigate questionable entries. Good knowledge and understanding of Claims and business/operating processes and procedures. Works to clearly defined procedures under close supervision.

RESPONSIBILITIES

• Review claim submissions to confirm required documents have been received, verify medical codes, eligibility, other insurance, authorizations, and account benefit plans.
• Follows established policies and procedures to pay, pend for additional information, or deny claims.
• Adapt to and positively influence change by accepting feedback with a growth mindset to continuously improve.
• Follow processes and work independently to meet or exceed Key Performance Indicators (KPI)
• Ability to effectively excel in a virtual work environment through active participation in team huddles, Supervisor 1×1 or check-ins,  using a variety of virtual tools, i.e. Outlook email, Skype for Business, Cisco Web-Ex or other similar applications.
• Maintains a high level of accuracy in all duties performed.
• Team members will be held accountable for meeting and maintaining minimum quality and production standards through use of Management Operating Systems (MOS) tools: Daily Production Log (DPL), Performance Profile, Claim Review tool, and other reporting systems.
• Partner with the Resource Management Group (RMG) on Workflow Tool (WFT), pended claims, or other inventory issues.
• Partner with Technical Coaches to understand claim processes and procedures.

QUALIFICATIONS

• High School diploma or equivalent.
• High level of computer navigational skills with experience using shortcut keys
• Proficient in Microsoft Office applications, Word, Excel, Outlook, OneNote, and Power Point
• Knowledge of medical and insurance industry terminology including CPT/ICD-10 codes preferred
• Medical coding knowledge preferred
• Excellent organizational, interpersonal, written and verbal communication skills
• Experience in delivering exceptional customer service
• Ability to perform comfortably in a fast-paced, deadline-oriented work environment
• Must be able to type and use a keyboard for extended periods of time
• Integrity and personal accountability for job performance and expectations
• Proven ability to learn a variety of benefit plans
• Ability to make a high volume of phone calls to providers to obtain required information

If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload.

For this position, we anticipate offering an hourly rate of 17 – 26 USD / hourly, depending on relevant factors, including experience and geographic location.

This role is also anticipated to be eligible to participate in an annual bonus plan.

We want you to be healthy, balanced, and feel secure. That’s why you’ll enjoy a comprehensive range of benefits, with a focus on supporting your whole health. Starting on day one of your employment, you’ll be offered several health-related benefits including medical, vision, dental, and well-being and behavioral health programs. We also offer 401(k) with company match, company paid life insurance, tuition reimbursement, a minimum of 18 days of paid time off per year and paid holidays. For more details on our employee benefits programs, visit Life at Cigna Group.