Job Description
Ready to take the next step in your career journey? The Eligibility Senior Representative implements and maintains eligibility of benefits for our patients with Blood Disorders. In this very specialized role, you'll be responsible to update, and maintain automated, direct connect and/or manual eligibility data. You'll Interact with internal partners, external clients, and vendors. You'll generate reports to identify and resolve discrepancies. Identify process improvement opportunities. May negotiate and resolve eligibility with clients. May provide technical support for the electronic processing of eligibility. Ensures customer data is installed accurately and timely. Acts as a liaison between both internal and external resources to facilitate the timely processing of referrals and provide accurate status reporting to clients.
How you'll make a difference: - Facilitates cross-functional resolution of drug coverage issues and proactively addresses, researches and resolves issues impacting revenue optimization
- Performs medical /pharmacy benefit verification requiring complex decision skills based on payer and process knowledge
- 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.)
- Directly interfaces with external clients, providing expert assistance to clients on patient status
- Liaison for company providing referral status reporting
- May negotiate pricing for non-contracted payers and authorize patient services and ensure proper pricing is indicated in RxHome
- Use discretion and independent judgement in handling complex escalated client complaints, escalating further as appropriate.
What you'll need to Succeed: - High school diploma or GED required; bachelor's degree preferred
- 3+ years of health care experience with medical insurance knowledge, terminology and patient access, preferred
- 1+ years of experience with pharmacy prior authorization, preferred
- 1+ years of experience with Accredo Specialty Pharmacy processes, preferred
- 1+ years of experience with the platform RX HOME and CSP, preferred
- Intermediate data entry skills and working knowledge of Microsoft Office, Excel and Outlook, Required
- Experience training and coaching less experienced staff with patience to explain details and processes repeatedly, preferred
- Excellent phone presentation and communication skills, required
- Demonstrated ability to handle challenging customers and escalated situations/ calls, in a professional manner, Required
- Adaptable, self-Starter with advanced problem-solving skills and the ability to work collaboratively with other departments and provide innovative solutions, Required
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 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.
Job Tags
Permanent employment, Local area, Remote job,