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 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.
• Collaborate with other stakeholders / teams to resolve queries including complex queries.
• Actively support all team members to enable operational goals to be achieved.
• Meet or exceed Service Level Agreement requirements, team KPI(s), monthly quality audit scores and NPS (Net Promoter Score).
• 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.
• 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.

Experience

At least 1-2 years of experience performing a similar role. 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. Excellent organizational skills, capable of following and contributing to agreed procedure. Strong administration awareness and experience, essential. Strong skills in Microsoft Office applications, essential. First class written and verbal communication skills, essential. Ability to communicate across a diverse population, essential. Capable of working independently, or as part of a team. Good time management, ability to work to tight deadlines. Flexible and adaptable approach, sometimes working in a fast-paced environment. Passion for achieving agreed objectives. Confident in calling out when facing issues. Should be flexible to work in shifts and on staggered weekends for overtime.

COMMUNICATIONS AND WORKING RELATIONSHIPS

Education: Graduate (Any) - medical, Paramedical, Commerce, Statistics, Mathematics, Economics or Science. Experience Range: Minimum 1-2 years and up to 3 years of experience in processing of healthcare insurance claims. Foundational Skills: Expertise in EU insurance claims processing. Work Timings: 7:30AM to 4:30PM IST (Flexible shift). Job Location: Bengaluru (Bangalore).

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About The Cigna Group

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.