The Appeals Processing Senior Representative 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

Qualifications:

• High School Diploma required
• 3+ years of 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
• OT required
• 2 holidays a year required to cover
• Bilingual Spanish a plus

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 19 - 29 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.

About Cigna Healthcare

Cigna Healthcare, a division of The Cigna Group, is an advocate for better health through every stage of life. We guide our customers through the health care system, empowering them with the information and insight they need to make the best choices for improving their health and vitality. Join us in driving growth and improving lives.

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.

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.