** Selected candidate must be located within driving distance of the Orlando , Florida office: 6272 Lee Vista Blvd., Orlando, FL 32822
**Selected candidate must be available to work at home and flex to rotate IN THE OFFICE 3 times per month with a start time of 9am to 6pm EST Monday thru Friday.
POSITION SUMMARY
The Eligibility Senior Representative delivers straight forward administrative and/or other basic business services in Eligibility. Implements and maintains eligibility for benefits. Implements, updates, and maintains automated, direct connect and/or manual eligibility data. Interacts with internal partners and/or external clients/vendors. Generates reports to identify and resolve discrepancies. Identifies process improvement opportunities for own cases. May negotiate and resolve eligibility with clients. May provide technical support for the electronic processing of eligibility. Ensures customer data is installed accurately and timely. Good knowledge and understanding of Eligibility and business/operating processes and procedures. Acts as a liaison between both internal and external resources to reduce client abrasion, facilitate the timely processing of referrals and provide accurate status reporting to clients
ESSENTIAL FUNCTIONS
Facilitates cross-functional resolution of drug coverage issues & proactively address, researches & resolves issues impacting revenue optimization.
Performs medical /pharmacy benefits verification requiring complex decision skills based on payer and process knowledge resulting in onboarding or no starting specialty patients.
Contacts benefit providers to gather policy benefits/limitations.
Coordinating and ensuring the services provided will be reimbursable (e.g., deductible amounts, co-payments, effective date, levels of care, authorization, etc.).
Directly interfaces with external clients.
Provide expert assistance to clients on patient status.
Liaison for the company providing referral status reporting.
May negotiate pricing for non-contracted payers and authorize patient services and ensure proper pricing is indicated in RxHome.
Handle Escalations.
Use discretion & independent judgment in handling pt or more complex client complaints, escalating as appropriate.
Completes other projects and additional duties as assigned.
QUALIFICATIONS
High school diploma or GED required bachelor’s degree preferred.
Must have a minimum of 3 years of relevant working experience.
Must have Health care experience with medical insurance knowledge and terminology and experience in patient access.
Intermediate data entry skills and working knowledge of Microsoft Office.
Excellent phone presentation and communication skills is REQUIRED.
Demonstrated ability to handle professionally challenging customers.
Ability to adapt in a dynamic work environment and make decisions with minimal supervision.
Advanced problem-solving skills and the ability to work collaboratively with other departments to resolve issues with innovative solutions.
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 Group.
About Evernorth Health Services
Evernorth Health Services, a division of The Cigna Group, creates pharmacy, care and benefit solutions to improve health and increase vitality. We relentlessly innovate to make the prediction, prevention and treatment of illness and disease more accessible to millions of people. 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.
Qualified applicants with criminal histories will be considered for employment in a manner consistent with all federal, state and local ordinances.
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