Remote Work from Home, USA
As an Appeals Processing Senior Representative you will conduct detailed appeals investigations 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
You are the right person if you have:
High School Diploma or GED required
3 or more years’ experience in Medicare Part C related to Appeals, Claims or Grievances preferred
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
Ability to work independently with strong attention to details
Systems: FileBound, HCiCMS, QCare, Provider Link, One View, QNXT, CCMS, PARC & OnBase, Medhoc
Flexable to work weekend or split schedule if needed
Competencies needed to be successful in this position:
Dealing with Ambiguity
Priority Setting
Learning and Applying Quickly
Problem Solving
Perseverance
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 .
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: [email protected] for support. Do not email [email protected] for an update on your application or to provide your resume as you will not receive a response.
Cigna 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.