Job Summary: Delivers specific Senior Eligibility Representative tasks assigned by a supervisor within a dedicated Cystic Fibrosis team. 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 and provides technical support for electronic eligibility processing. Ensures customer data is installed accurately and timely. Analyzes customized client formats and may work directly with Systems to design formats. Provides recommendations to decrease errors. Demonstrates thorough technical knowledge of manual and automated eligibility. Completes day-to-day Senior Eligibility tasks independently, with access to guidance from senior team members. Tasks involve forward planning and anticipation of needs/issues. Resolves non-routine issues escalated from junior team members. Cross-training in multiple systems and business areas of Patient Access is required to support broader team functionality and ensure seamless patient care.
Job Description: Delivers advanced administrative and business services in Eligibility as part of a dedicated Cystic Fibrosis team. Implements and maintains eligibility for benefits, including automated, direct connect, and manual data. Interacts with internal partners and external clients/vendors. Generates reports to identify and resolve discrepancies and identifies process improvement opportunities. May negotiate and resolve eligibility issues with clients and provide technical support for electronic processing. Ensures customer data is installed accurately and timely. May work with client formats and internal Systems to resolve errors and technical issues. Demonstrates advanced knowledge of manual and automated eligibility, reporting tools, and systems. Issues may be complex and require independent judgment. Works under defined procedures with minimal supervision. Cross-training in multiple systems and business areas of Patient Access is required, enabling team members to support various functions and ensure continuity of care for patients with complex needs.
What you'll do:
Facilitates cross-functional resolution of drug coverage issues & proactively address, research & resolve issues impacting referral turn-around time
Independently resolve basic patient claims issues using key subject matter knowledge
Prepare and review claims to ensure accuracy to payer requirements, including but not limited to codes, dates and authorizations
Effectively collaborate with internal departments to resolve issues or provide any needed information
Contact benefit providers to gather policy benefits/limitations
Coordinate and ensure services provided will be reimbursable (e.g., deductible amounts, co-payments, effective date, levels of care, authorization, etc.)
Perform medical/pharmacy benefit verification requiring complex decision skills based on payer and process knowledge What you'll need:
High school diploma or GED
2 plus years of relevant working experience required
Experience with health care, medical insurance terminology and patient access preferred
Strong data entry skills and computer skills
Excellent phone presentation and communication skills
Demonstrated ability to handle difficult conversations in a professional manner
Ability to adapt in a dynamic work environment and make decisions independently
Advanced problem-solving skills and the ability to work collaboratively with other departments 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.
For this position, we anticipate offering an hourly rate of 19 - 29 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.
At The Cigna Group, 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), 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, click here (https://jobs.thecignagroup.com/us/en/benefits) .
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 need a reasonable accommodation to complete the online application process, please email seeyourself@thecignagroup.com for assistance. Please note that this email inbox is dedicated to accommodation requests only and cannot provide application updates or accept resumes.
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.
Qualified applicants with criminal histories will be considered for employment in a manner consistent with all federal, state and local ordinances.
