Claims representative - Cigna Healthcare

Overview

Claim Representative role in the Claims department at CIGNA Healthcare, serving providers and insurance companies by processing medical insurance claims and pre-approvals per policy terms.

What you'll do

• Process claims from members and providers.
• Assist queries from providers and payers via phone calls or e-mails.
• Maintain files for authorizations and other reports.
• Assess and process claims in line with policy coverage and medical necessity.
• Be fully versed with medical insurance policies for various groups / beneficiaries.
• May assist in training colleagues and share knowledge.
• Accurately assess eligibility within policy boundaries.
• Monitor and maintain claims processing as per the defined terms and policy of the organization.
• Achieve required processing targets assigned by the team leader on daily, weekly and monthly basis.
• Monitor qualitative and quantitative measures for claims and pre-approvals.
• Ensure compliance with any changes in system parameters or process.
• Maintain quality as per framework for accuracy.
• Maintain productivity and responsiveness to work allocated.
• Collaborate with other stakeholders / teams to resolve queries, including complex queries.
• Actively support team members to enable operational goals to be achieved.
• Meet or exceed Service Level Agreement requirements, team KPI(s), monthly quality audit scores and NPS (Net Promoter Score).
• Assess and process claims for medical expenses while maintaining medical confidentiality.
• Input data accurately into system applications.
• Position yourself analytically and critically in the context of cost management and existing working methods.
• Follow up own workload (volume and timing), monitoring chronology and processing time and taking suitable actions.
• Participate efficiently in processing the flow of claims: inform the supervisor about claims lacking clarity and about possible ways of optimizing processes.
• Monitor and highlight high-cost claims and ensure relevant parties are aware.
• Follow Claim Manual and SOP strictly, adjudicate claims according to benefit policies, and meet financial/procedure accuracy and TAT targets on claims adjudication.
• Adjust error claims according to actual situation.
• Handle recoupment and reconciliation work, communicating with providers and members via call and email for collection and explanation.
• Work with cross-functional teams such as Finance, CSR, Eligibility, Network and Client Management to ensure recoupment work goes smoothly.
• Actively support the Team Leader and work with claim colleagues to achieve all operational goals.

What you'll need

• At least 1-2 years of experience performing a similar role.
• Graduate (any) in medical, paramedical, commerce, statistics, mathematics, economics or science.
• Minimum 1-2 years and up to 3 years of experience in processing healthcare insurance claims.
• Expertise in EU insurance claims processing.
• Strong administration awareness and experience.
• Strong skills in Microsoft Office applications.
• First-class written and verbal communication skills.
• Ability to communicate across a diverse population.
• Excellent organizational skills, capable of following and contributing to agreed procedure.
• Capable of working independently or as part of a team.
• Good time management and ability to work to tight deadlines.
• Flexible and adaptable approach, sometimes working in a fast-paced environment.
• Passion for achieving agreed objectives.
• Confident in calling out when facing issues.
• Flexible to work in shifts and on staggered weekends for overtime.

Nice to have

• Experience of working for an international company.
• Claims processing or insurance experience.
• Broad awareness of medical terminology.

Details

• Job location: Bengaluru (Bangalore), India.
• Work timings: 7:30AM to 4:30PM IST (flexible shift).
• Shift work and staggered weekend overtime may be required.
• Reports to Claim Supervisor or Manager; Band 1; Claims department.