CIGNA Healthcare
ClaimsRepresentative
Neural analysis suggests this role is
optimal for Entry candidates.
“Claims Representative at CIGNA Healthcare. Skills: Claims processing, insurance, medical insurance policies, medical confidentiality, cost management, recoupment and reconciliation work, healthcare insurance claims processing. Processes claims from members and providers. Assists queries from providers and payers via phone calls or e-mails”
What You'll Achieve.
Achieves required processing targets assigned by the team leader on daily, weekly and monthly basis; Monitors the qualitative and quantitative measures for claims & pre-approvals; Maintains quality as per framework for accuracy; Maintains productivity and responsiveness to the work allocated; Meet or exceed Service Level Agreement requirements, team KPI(s), monthly quality audit scores and NPS (Net Promoter Score); Follow Claim Manual and SOP strictly, adjudicate claims according to benefit policies, and meet both financial/procedure accuracy and TAT target on claims adjudication
Industry & Context.
Positioning him/herself analytically and critically in the context of cost management and in respect of existing working methods; inform the supervisor about claims lacking clarity and about possible ways of optimizing the processes
Should be flexible to work in shifts and on staggered weekends for overtime
What They're Looking For.
Must Have
administration awareness and experience, essential, skills in Microsoft Office applications, essential, First class written and verbal communication skills, essential, Ability to communicate across a diverse population, essential
Nice to Have
Experience of working for an international company, preferred but not essential, Claims processing or insurance experience, preferred but not essential, Broad awareness of medical terminology, advantageous
What You'll Do.
Processes claims from members and providers
Assists queries from providers and payers via phone calls or e-mails
Maintains files for authorizations and other reports
Assesses and processes claims in line with the policy coverage and medical necessity
Be fully versed with medical insurance policies for various groups / beneficiaries
May assist in training colleagues and asked to share knowledge
Accurately assesses eligibility within the policy boundaries
Monitors and maintains the claims processing as per the defined terms and policy of the organization
Achieves required processing targets assigned by the team leader on daily
weekly and monthly basis
Monitors the qualitative and quantitative measures for claims & pre-approvals
Ensures compliance to any changes in terms of system parameters or process
Maintains quality as per framework for accuracy
Maintains productivity and responsiveness to the work allocated
Assessing and processing claims for medical expenses while always bearing in mind the importance of medical confidentiality
Accurate data input to the system applications
Positioning him/herself analytically and critically in the context of cost management and in respect of existing working methods
Following up own workload (volume and timing): keeping an eye on chronology and processing time of the work volume and taking suitable actions
Participate efficiently in processing the flow of claims: inform the supervisor about claims lacking clarity and about possible ways of optimizing the processes
A sustained effort towards high-quality claims handling
accurate reimbursements and fast transactions are important motivators
Monitor and highlight high-cost claims and ensure relevant parties are aware
Follow Claim Manual and SOP strictly
adjudicate claims according to benefit policies
and meet both financial/procedure accuracy and TAT target on claims adjudication
Adjust error claims according to actual situation
Well handle recoupment and reconciliation work
communicate with providers and members via call and email for collection and explanation
How You'll Work.
Team & Collaboration
Collaborate with other stakeholders / teams to resolve queries including complex queries; Actively support all team members to enable operational goals to be achieved; Work with cross function teams, such as Finance, CSR, Eligibility, Network, Client Management, etc. Ensure recoupment work go smoothly; Actively support Team Leader and work with claim colleagues to enable all operational goals to be achieved
Communication Scope
First class written and verbal communication skills; Ability to communicate across a diverse population; foster internal and external communication standards
Full Job Description
# JOB DESCRIPTION **POSITION : Claim Representative A** **REPORTING TO** **: Claim Supervisor or Manager** **DEPARTMENT : Claims** **Career Band : Band 1** ** _About US_** At CIGNA Healthcare we are guided by a common purpose to help make financial lives better through the power of every connection. Responsible Growth is how we run our company and how we deliver for our clients, teammates, communities, and shareholders every day. One of the keys to driving Responsible Growth is being a great place to work for our teammates around the world. We are devoted to being a diverse and inclusive workplace for everyone. We hire individuals with a broad range of backgrounds and experiences and invest heavily in our teammates and their families by offering competitive benefits to support their physical, emotional, and financial well-being. CIGNA Healthcare believes both in the importance of working together and offering flexibility to our employees. We use a multi-faceted approach for flexibility, depending on the various roles in our organization. Working at CIGNA Healthcare will give you a great career with opportunities to learn, grow and make an impact, along with the power to make a difference. Join us! **JOB PURPOSE** The job holder is responsible of serving providers and insurance companies by determining requirements, answering inquiries, resolving problems, fulfilling requests and maintaining database. He/She is responsible for processing as per terms of benefits. He/She should provide accurate and relevant medical coverage details and maintain pre-approvals and claims processing as per the defined terms and policies of the organization. **RESPONSIBILITIES AND DUTIES** * Processes claims from members and providers. * Assists queries from providers and payers via phone calls or e-mails. * Maintains files for authorizations and other reports. * Assesses and processes claims in line with the policy coverage and medical necessity. * Be fully versed with medical insurance
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