Hoover, United States
over 1 year ago
Candidate will receive the following Cigna equipment that will be due at the end of assignment: badge and laptop
Delivers specific delegated tasks assigned by a supervisor in the Case Management job family.
Completes day-to-day Case Management 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
Review, research and understand how request for plan services and claims submitted by consumers (members) and physicians/providers was processed and determine why it was denie.
Identify and obtain all additional information (relevant medical records, contract language and process/procedures) needed to make an appropriate determination of the appeal.
Make an appropriate administrative determinations as to whether a claim should be approved or denied based on the available information and as well as research and provide a written detailed clinical summary for the Plan Medical Director.
Determine whether additional pre service, appeal or grievance reviews are required and/or whether additional appeal rights are applicable and then if necessary, route to the proper area/department for their review and decision/response
Complete necessary documentation of final documentation of final determination of the appeals using the appropriate system applications, templates, communication process, etc. Communicate appeal information to members or providers with the required timeframes well as to all appropriate internal or external parties (regulatory agencies, plan administrators, etc.) Meet the performance goals established for the position in the areas of: 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.
Read Medicare guidance documents report and summarize required changes to all levels department management and staff.
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. .
Assist with monitoring, inquiries, and audit activities as needed.
Additional duties as assigned.