Cigna Medicare Part C Non-Clinical Appeals Reviewer (Appeals Sr Associate) HealthSpring in Nashville, Tennessee
Updates appeals tracking system, consults with Appeals Analyst Specialist regarding technical claims issues; determines required expert resources at each juncture and solicits input. Based on appeal investigation, determines whether claim is reopened or original denial was appropriate. Proactively communicates with appellants, leadership team, providers, and the original case manager to resolve investigation issues and communicate decisions/rationale for denial/approval.
• Responsibilities include: timely completion of appeals investigation, fairness of administrative decisions, timely notification and development of case summary to include IRE packet development
• Requires the ability to consistently apply appropriate administrative and regulatory criteria for reviewing and making decisions on all non-clinical appeals and validating the accuracy of all received information
• Requires the ability to consistently apply appropriate administrative and regulatory criteria
• Requires effective communication abilities (written and verbal) when documenting actions and communications with Members, Providers, Medical Director and appeals leadership.
• The role works closely with the multiple other roles and requires the ability to communicate status variances
• This role serves as a communication bridge between the appeals department and the claims department
• Responsible for maintaining and prioritizing work load to support appeal timeliness and communicate risks, concerns or opportunities to leadership related to their work load.
HS Diploma required
A minimum of 2 years of experience with Medicare appeals/claims/grievances required
Familiarity with state and federal regulations, medical terminology and coding.
Excellent problem solving skills
Primary Location: Nashville-Tennessee
Work Locations: 530 Great Circle Road Nashville 37228
Job: Med Mgt--Med Review & Appeals
Employee Status: Individual Contributor
Job Type: Full-time
Job Level: Day Job
Job Posting: Mar 12, 2018, 4:20:04 PM
Cigna is an equal opportunity employer, which means we offer equal treatment to all applicants. Cigna does not discriminate, either directly or indirectly, on the grounds of race, color, sex, gender identity, sexual orientation, nationality, national origin, ethnic origin, religion, beliefs or creed, age, disability, marital status, veteran status or genetic information in any area of recruitment. In some countries we ask for information on the ethnic origin, gender and disability of our applicants for the purpose of monitoring equal opportunity. If you have a disability and would like to indicate as part of your application any relevant effects of your disability and any adjustment which you consider should reasonably be made to the process to assist your application, please do so in the relevant field during the application process.