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Eligibility Senior Representative

3 months ago

Pennsylvania, United States The Cigna Group Full time

Delivers specific delegated Eligibility tasks assigned by a supervisor. Implements, updates, and maintains automated, direct connect and/or manual eligibility data. May handle National Accounts or more complex accounts. Reconciles accounts for non-standard requests. May provide technical support for the electronic procession of eligibility. Ensures customer data is installed accurately and timely. Analyzes formats that are customized directly by the client. May work directly with Systems to design formats. Provides recommendations to decrease errors. Thorough technical knowledge of manual and automated eligibility. Completes day-to-day Eligibility tasks without immediate supervision, but has ready access to advice from more experienced team members. Tasks involve a degree of forward planning and anticipation of needs/issues. Resolves non-routine issues escalated from more junior team members.


Job Description:

The Eligibility Senior Representative delivers straight forward administrative and/or other basic business services in Eligibility. Implements and maintains eligibility for benefits. Implements, updates, and maintains automated, direct connect and/or manual eligibility data. Interacts with internal partners and/or external clients/vendors. Generates reports to identify and resolve discrepancies. Identifies process improvement opportunities for own cases. May negotiate and resolve eligibility with clients. May provide technical support for the electronic processing of eligibility. Ensures customer data is installed accurately and timely. Good knowledge and understanding of Eligibility and business/operating processes and procedures. Acts as a liaison between both internal and external resources to reduce client abrasion, facilitate the timely processing of referrals and provide accurate status reporting to clients

Location: Remote-Work at Home

ESSENTIAL FUNCTIONS:

  • Facilitates cross-functional resolution of drug coverage issues & proactively address, researches & resolves issues impacting revenue optimization.
  • Performs medical /pharmacy benefits verification requiring complex decision skills based on payer and process knowledge resulting in onboarding or no starting specialty patients.
  • Contacts benefit providers to gather policy benefits/limitations.
  • Coordinating and ensuring the services provided will be reimbursable (e.g., deductible amounts, co-payments, effective date, levels of care, authorization, etc.).
  • Directly interfaces with external clients.
  • Provide expert assistance to clients on patient status.
  • Liaison for the company providing referral status reporting.
  • May negotiate pricing for non-contracted payers and authorize patient services and ensure proper pricing is indicated in RxHome.
  • Handle Escalations.
  • Use discretion & independent judgment in handling pt or more complex client complaints, escalating as appropriate.
  • Completes other projects and additional duties as assigned.


JOB QUALIFICATIONS:

  • High school diploma or GED required, bachelor's degree preferred
  • At least 2-3 years of related working experience.
  • Must have Health care experience with medical insurance knowledge and terminology and experience in patient access.
  • Intermediate data entry skills and working knowledge of Microsoft Office.
  • Excellent phone presentation and communication skills.
  • Demonstrated ability to handle professionally challenging customers.
  • Ability to adapt in a dynamic work environment and make decisions with minimal supervision.
  • Advanced problem-solving skills and the ability to work collaboratively with other departments to resolve issues with innovative solutions.

Start Date: 9/30/24

Hours: Training will be 8/8:30am- 5/5:30pm, Monday- Friday.

Post Training Hours: Must have availability for a shift between the hours of 8am-8pm, Monday-Friday

ABOUT THE DEPARTMENT:

Through our range of health care products and services offered, Accredo team members provide in-depth care for patients with chronic health conditions like hemophilia, oncology, rheumatoid arthritis and growth hormone deficiency. In addition to health care products, we provide comprehensive management services – including outcomes measurement, counseling, clinical care management programs, social services, and reimbursement services. By performing in these very high-touch roles, employees have a daily opportunity to make a positive impact on their patients' lives.

NOTE: We are currently training in a work at home environment, and you will be required to have reliable internet connectivity provided through a wired connection. A mobile or hot spot environment is not acceptable and you may need to purchase an Ethernet cord depending on your current set up.


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.

About Evernorth Health Services

Evernorth Health Services, a division of The Cigna Group, creates pharmacy, care and benefit solutions to improve health and increase vitality. We relentlessly innovate to make the prediction, prevention and treatment of illness and disease more accessible to millions of people. Join us in driving growth and improving lives.

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: for support. Do not email for an update on your application or to provide your resume as you will not receive a response.

The Cigna Group 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.