Medicare Advantage Appeals Processing Representative - Cigna Healthcare - Remote

This position is full-time (40 hours/week) with the scheduled core business hours generally 8:00- 5:00 CST - Monday- Friday with occasional weekends and holiday coverage.

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 or GED 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, QCare, OneView, QNXT