Claims Lead Representative Job Overview:

• Researches, analyzes and calculates claims in accordance with provider contracts


• Works with internal matrix partners to resolve pended claims/tickets issues


• Utilizes SRS to route work items to matrix partners and external retailer claim administration staff


• Follow audit protocols and workflows to ensure quality goals.


• Special pricing projects as requested by retailers


• Partners with matrix organizations to ensure that appropriate action is taken to identify and implement high potential process improvements


• Supports and drives process improvement to further enhance claim accuracy outcomes


• Engagement, partnership with supervisor, claim processing team, and other internal and external partners


• Position requires excellent interpersonal skills; ability to understand and interpret policy provisions, and to present report analysis and meaningful findings in a clear, concise way.


• Pricing identification of errors and management of resolution with provider contracting/maintenance internal teams.


• Identifies steps necessary to process a varying complexity of contracts for pricing accuracy


• Other duties as assigned

Qualifications:

• 3+ years of claim processing technical knowledge and application experience required, ideally from healthcare


• Customer Service Driven; ability to meet and exceed the internal partner and external customer expectations


• Take accountability in critical thinking and decision making outcomes


• Problem solving skills; utilization of technical skills and resources to ensure accuracy of final claim resolution


• Strong communication skills, both verbal and written


• Ability to teach, educate, coach others through a variety of claim complexities


• Process improvement skills; ability to assess trends, processes, and barriers to drive positive outcomes for claim resolutions


• Fluent understanding and application of key tools and resources for claim processing; KnowledgeXchange, Calculators, CPF/PWB, SANP, Facets, etc.


• Comfortable working with others in multiple locations; office and work at home


• Basic knowledge with Word, Excel, PowerPoint, WebEx and Outlook preferred

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 21 - 32 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 Group .

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: SeeYourself@cigna.com for support. Do not email SeeYourself@cigna.com 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.

Qualified applicants with criminal histories will be considered for employment in a manner consistent with all federal, state and local ordinances.