Evernorth

The job profile for this position is Appeals Processing Senior Representative, which is a Band 2 Professional Career Track Role.

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We value our talented employees, and whenever possible strive to help one of our associates grow professionally before recruiting new talent to our open positions. If you think the open position you see is right for you, we encourage you to apply!

Our people make all the difference in our success.

The Clinical Coder conducts outpatient post-service administrative claims or appeals coverage determinations (such as bundling reviews) for which they are empowered outside of our company's clinical unit manager program requirements. This role applies all benefit plan limitations or exclusions and applicable federal and state regulatory requirements to each case review, including Patient Protection and Affordable Care Act. The Clinical Coder also keeps all HIPAA regulatory requirements.

Responsibilities

• Makes coverage determinations only on retrospective administrative OP claims/appeals such as bundling reviews using standard NAO and claims policies and procedures and company administrative guidelines.
• Research claims and appeals information, submitted review request letters or referrals and related materials in order to make coverage determinations on retrospective OP claims/appeals such as bundling reviews.
• Accurately screens any claim referral or appeal subject to state or federal mandates in order to correctly make coverage determinations on retrospective administrative outpatient claims/appeals such as bundling.
• Confirms appeal set up to meet state regulatory requirements on non-ASO appeals.
• Communicates approval or denial determinations made on retrospective administrative outpatient claims/appeals such as bundling reviews as required.
• Documents all retrospective administrative OP claims/appeals such as bundling reviews in the appropriate unit manager and appeals/calls systems as directed by the National Appeals Organization (NAO) policies and procedures.
• Manages assigned workload to completion within timeliness metrics as set forth by ERISA, state mandates, PPACA, NCQA and URAC.
• Completes all required training per regulatory and credentialing body standards.
• When requesting protected health information (PHI) from external or internal sources, employee limits requests for information to reasonably necessary information required to accomplish the intended purpose; accesses the minimum necessary amount of protected health information (PHI) needed to perform job functions; limits the health information disclosed to the amount reasonably necessary for its intended purpose on all routine or recurring disclosures of protected health information (PHI).

Qualifications

• High school diploma or GED required.
• Coding certification: CCS-P (Certified Coding Specialists-Physician based) or CPC (Certified Professional Coder) certification through AHIMA or AAPC) required.
• 1+ years of experience with CPT-4 and ICD-9/ICD-10 coding preferred.
• Familiarity with state and federal regulations preferred.
• 2+ years of experience in billing, claims, customer service, or health insurance highly preferred.
• Good research and analytic skills per employee work history.
• Proven ability to work independently.
• Demonstrated good judgment.
• Proven detail orientation
• Strong organizational skills
• Strong knowledge in medical terminology, anatomy and physiology.

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 19 - 29 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.

We want you to be healthy, balanced, and feel secure. That’s why 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) with company match, company paid life insurance, tuition reimbursement, a minimum of 18 days of paid time off per year and paid holidays. For more details on our employee benefits programs, visit Life at Cigna.

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.

Please note that you must meet our posting guidelines to be eligible for consideration. Policy can be reviewed at this link.

Qualified applicants with criminal histories will be considered for employment in a manner consistent with all federal, state and local ordinances.