Appeals Processing Senior Representative - Evernoth - Remote

Position Summary

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.

This role is for a Medical Coder; not Appeals Processing.

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 education or GED required.

• Required coder certification; only accepted for 2 programs: AAPC (American Academy of Professional Coders): CPC (Certified Professional Coder) or AHIMA (American Health Information Management Association): CCS-P (Certified Coding Specialists-Physician based). Note: Apprentice stage of certification is not eligible.

• 1+ year experience CPT-4 and ICD-9/ICD-10 coding experience preferred.

• Familiarity with state and federal regulations preferred.

• Greater than 2 years’ experience in billing, claims, customer service, or health insurance 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.

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 and paid holidays. 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 [email protected] 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.