Job Description

POSITION RESPONSIBILITIES

The Claims Examiner is responsible for the accurate and timely processing of medical, dental, vision and prescription drug claims. The incumbent is expected to provide courteous and prompt responses to customer inquiries.

The incumbent is expected to communicate professionally with peers, supervisors, subordinates, vendors, customers, and the public, and to be respectful and courteous in the conduct of this position.

ESSENTIAL JOB FUNCTIONS:

• Essential job functions include the following. Other functions may be assigned as business conditions change.
• Verifies the accuracy and receipt of all required documentation for each claim submitted.
• Collaborates with providers, plan participants, other claims payers, or any other party necessary to obtain information necessary to accurately process a claim.
• Analyzes information necessary for processing. This includes, but is not limited to, general participant and provider information, managed care affiliation, diagnosis codes, dates, place, type of service, procedure codes, and charges.
• Assures that the system processes the claim correctly and determines payment according to the plan as written.
• Word-processes correspondence to plan participants and providers in reference to pre-determinations and in response to basic benefit questions.
• Answers telephone calls from plan participants, group contacts, and customer service representatives pertaining to benefits and claims inquiries.
• Resolves problematic claims with the assistance of the Team Leader, Claims Manager and/or the Director of Claims.
• Assigns critically ill patients to large case management. Assists the case manager with direct negotiation and the efficient use of benefits.
• Assists other examiners as needed due to workload requirements, including assigned back-up when examiners are absent.
• Aids the Team Leader and/or the Claims Manager in the resolution of claim appeals and disputes by providing documentation for review.
• Researches, calculates and requests refunds when necessary.
• Contributes to the daily workflow with regular and punctual attendance.
• Thoroughly researches and completes renewal reports in a timely manner in consultation with the Marketing Department.
• Process eligible claims on groups before the end of their stoploss contract renewal period.
• Assists the Legal Department with subrogation claims as necessary.
• Attends various group meetings as required.
• Assists with audits as needed.
• Assists with plan benefit set-up and changes as needed.

Minimum Education: High school graduation or GED required.

Minimum Experience: Basic computer and customer service experience required.

Other Qualifications:

• Excellent oral and written communication skills required.
• PC skills, including Windows and Word.
• Ability to learn all functions of the claims processing software as is necessary for claims processing and adjudication.
• Must be able to adapt to software changes as they occur.
• Typing ability of 45 wpm net
• Excellent listening skills.
• Basic mathematical skills.
• High level of interpersonal skills to work effectively with others.
• Ability to organize and recall large amounts of detailed information.
• Ability to read, analyze and interpret benefit summary plan descriptions, insurance documents, plan benefits, and regulations and make appropriate applications to specific situations.
• Ability to meet productivity standards with 99% financial accuracy and 95% procedural accuracy.
• Thorough knowledge of claims processing procedures and requirements.
• Ability to project a professional image and positive attitude in any work environment.
• Ability to comply with privacy and confidentiality standards.
• Ability to be flexible, work under pressure and meet deadlines.
• Ability to analyze and solve problems with professionalism and patience, and to exercise good judgment when making decisions.
• Ability to operate typical office equipment.
• Working knowledge of general office procedures.

About Allegiance by Cigna Healthcare

Since 1981, Allegiance by Cigna Healthcare has specialized in administering medical benefits, including claims processing, customer service, utilization management, and case management. With a high‑touch approach to member and client service, Allegiance supports some of the nation’s most innovative health benefit strategies.

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 Cigna Healthcare

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.

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.