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Claims Representative

Job Description
The job profile for this position is Claims Representative, which is a Band 1 Professional Career Track role.
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Claims Representative
Help customers maintain their financial well-being and peace of mind by accurately and timely processing Supplemental Health claims while safeguarding confidential customer information. SHS Claim Representatives support customers experiencing unexpected accidents, illnesses, and hospital stays by adjudicating claims and ensuring benefits are administered according to plan provisions.
Under direct supervision, advocates perform duties related to the adjudication of Supplemental Health claims, including reviewing claim documentation, verifying eligibility and coverage, interpreting policy provisions, determining benefit eligibility, managing pending claims, and issuing claim decisions. New advocates participate in a structured training program that includes virtual classroom instruction, on-the-job coaching, and gradual increases in productivity and quality expectations. Upon completion of training, advocates are expected to meet established quality, productivity, and performance standards.
Responsibilities

• Independently review claim submissions to confirm required documents have been received, verify medical codes, eligibility, other insurance, authorizations, and account benefit plans.

• Follows established policies and procedures to pay, pend for additional information, or deny claims.

• Adapt to and positively influence change by accepting feedback with a growth mindset to continuously improve.

• Follow processes and work independently to meet or exceed Key Performance Indicators (KPI)

• Ability to effectively excel in an on camera virtual work environment through active participation in team huddles, Supervisor 1x1 or check-ins, using a variety of virtual tools, i.e. Outlook email, TEAMS for Business, Cisco Web-Ex or other similar applications.

• Maintain self-discipline, consistently uphold a strong work ethic, and complete work tasks/responsibilities while working without close supervision.

• Maintains a high level of accuracy in all duties performed.

• Utilize multiple computer applications simultaneously.

• Identify discrepancies, errors, or missing information.

• Team members will be held accountable for meeting and maintaining minimum quality and production standards through use of Management Operating Systems (eMOS) tools: Daily Production Log (DPL), Performance Profile, Ring Master, SAM3, and other reporting systems.

• Partner with the Resource Management Group (RMG) on Workflow Tool (WFT), COGNOS pend report claims, or other inventory issues.

• Identify claim processing learning opportunities by working directly with supervisors, coaches, and trainers to learn efficient and effective processing techniques and workflows.

• Work independently in a virtual environment while demonstrating accountability, professionalism, and strong time management skills.

• Maintain confidentiality and compliance with company policies and regulatory requirements.

Experience Required:

• High School diploma or equivalent

• Must possess strong attention to detail and problem-solving skills with a high level of accuracy

• High level of navigating multiple computer applications using shortcut keys and other techniques

• Proficient in Microsoft Office applications, Word, Excel, Outlook, OneNote, and Power Point

• Knowledge of medical and insurance industry terminology including CPT/ICD-10 codes required

• Proven experience in health insurance claims processing or similar field preferred

• Excellent organizational, interpersonal, written and verbal communication skills

• Strong organizational skills to maximize available work time. Ability to prioritize tasks to ensure job tasks are completed before deadlines

• Experience in delivering exceptional customer service

• Ability to perform comfortably in a fast-paced, deadline-oriented work environment

• Must be able to type and use a keyboard for extended periods of time

• Integrity and personal accountability for job performance and expectations

• Ability to interpret policy language and apply complex benefit provisions

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 17.75 - 26 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.

At The Cigna Group, 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), company paid life insurance, tuition reimbursement, a minimum of 18 days of paid time off per year, paid holidays, and leaves of absence. For more details on our employee benefits programs, click here.

About The Cigna Group
Doing something meaningful starts with a simple decision, a commitment to changing lives. At The Cigna Group, we’re dedicated to improving the health and vitality of those we serve. Through our divisions Cigna Healthcare and Evernorth Health Services, we are committed to enhancing the lives of our clients, customers and patients. 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 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.
Originally posted on Himalayas