Job Description

The Clinical Appeals Senior Associate (CASA) collects non-clinical data utilizing pre-formatted templates and transfers this information to the clinical professional staff; screens information from targeted claims related to clinical and mental health services, clinical/mental health denial/appeal letters and their respective submitted records for denied clinical/mental health services for the pre-formatted transactional template. The CASA performs other assignments that do not require evaluation or interpretation of clinical information; consults with Utilization Review Nurses, Licensed Clinical Managers and Clinical Quality Program Support personnel; determines required expert resources at each juncture and solicits input appropriately. Licensed Health Professionals (clinical staff) are available to the non-clinical staff while they are performing their duties via face-to-face availability, telephonic or electronic connectivity. Proactively communicates with claimants, employers, providers and the original case manager, if applicable, to resolve investigation issues and communicate decisions/rationale for denial or approval as directed by clinical personnel, if applicable. Conducts OP post-service administrative claims or appeals coverage determinations (such as bundling reviews) for which they are empowered outside of Cigna\'s clinical UM program requirements. Applies all benefit plan limitations/exclusions and applicable federal and state regulatory requirements to each case review, including PPACA. Keeps up with all HIPAA regulatory requirements.

Major Job Responsibilities and Required Results

• Researches claim and appeal information, submitted review request letters or referrals and related materials in order to set up referral templates for the clinical nurse/medical director
• Applies the Benefit and Coverage Determination Policy hierarchy guidelines to each case review template set-up (see National Policy), as applicable
• Accurately screens any claim referral or appeal subject to state or federal mandates in order to correctly prep the case for the clinical team
• Confirms appeal set up to meet state regulatory requirements on non-ASO appeals
• Completes resolution letters in compliance with all PPACA and/or state regulatory requirements, as well as ERISA and credentialing body requirements, when needed
• Completes resolutions letters with correct grammar, complete thought content, correct spelling and required regulatory fonts, as applicable
• Completes resolution letters to address all appeal issues noted in the appeal letter request when needed
• Documents all reviews as conducted by the clinical review staff and medical directors in the appropriate UM 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

Qualifications:

• Greater than 2 years\xe2\x80\x99 experience in billing, claims, customer service or health insurance
• Good research and analytic skills per employee work history
• Proven ability to work independently
• Demonstrated good judgment
• Proven detail orientation
• Strong organizational skills
• Medical terminology proficiency
• CPT-4 and ICD-9 coding experience
• High school education or GED
• Function in a team based/matrix environment
• Strong commitment, drive and motivation to provide excellent customer service
• Ability to meet deadlines and multi-task in a production based environment

Preferred Requirements

• Familiarity with state and federal regulations
• Coding certification
• 3 years (or more) of claim adjudication experience

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 The Cigna Group

Doing something meaningful starts with a simple decision, a commitment to changing lives. At The Cigna Group, we\xe2\x80\x99re 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 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.

Cigna