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The job profile for this position is Appeals Processing Representative, which is a Band 1 Professional Career Track Role.
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Medicare Appeals Processing Representative
Conducts detailed investigation of all supporting documents to determine how to correctly enter the appeal data in the appropriate data system. Proactively communicates with appellants, leadership team, providers and the original case manager to resolve investigation issues and to ensure the appeal is processed within applicable guidelines.
This position is full-time (40 hours/week) with the scheduled core business hours Monday-Friday, 9-6pm CST preferred. Occasional weekend or holiday coverage required.
Job Requirements include, but not limited to:
• Ability to differentiate different types of requests Appeals, Grievances, coverage determination and Organization Determinations in order to ensure the correct processing of the appeal.
• Excellent prioritization and organizational skills; effectively manage competing priorities and multiple deadlines.
• 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
• 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
• 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
• Complete necessary documentation and correctly enter data in the appropriate system applications, templates, communication process, etc.
• Meet the performance goals established for the position in the areas of: productivity, efficiency, accuracy, quality, member satisfaction and attendance
• Adhere to department workflows, desktop procedures, and policies.
• Work with all matrix partners to ensure accurate and timely processing of Medicare Appeals.
• Support the implementation of new process as needed.
• Based on case work and departmental reporting, ability to identify and report trends and/or areas of opportunities to department management and peers. .
• Understand and investigate billing issues, claims and other plan benefit information.
• Additional duties as assigned.
Qualifications
• Education: Minimum High School Diploma Required. Prefer background as a medical assistant or prior Medicare Claims experience
• 1+years’ experience in Medicare Advantage Health Plans or related experience in a healthcare setting handling complex inquiries and requests for service.
• Good knowledge and understanding of Appeals Processing and business/operating processes and procedures.
• Working knowledge of Medicare Advantage, Original Medicare and or Medicaid appeal regulations.
• Superb written and oral communication skills.
• Must have the ability to work objectively and provide fact based answers with clear and concise documentation.
• Proficient in Microsoft Office products (Access, Excel, Power Point, Word).
• Prioritizes workflow on a consistent basis, applies key HIPAA and CMS guidelines in daily workflow, and meets turnaround times for assigned cases.
• Ability to multi-task and meet multiple competing deadlines.
• Ability to work independently and under pressure.
• Attention to detail and critical thinking skills.
Systems: MHK, OneView, QNXT, Facets
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 – 25 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.
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.
Please note that you must meet our posting guidelines to be eligible for consideration. Policy can be reviewed at this link.
