Eligibility Senior Representative

Job Description:

The Eligibility Senior Representative performs specialized patient access functions requiring an advanced understanding of insurance benefits and processes to successfully communicate with Payers, Pharma, Physicians, and Patients. Relies on experience and knowledge of industry best practices to communicate knowledge of pending referrals that may have an adverse impact on the patient experience. This individual can proactively recognize trends, identify and clarify patients’ needs, and work towards solutions.  

ESSENTIAL FUNCTIONS:

• Facilitate cross-functional resolution of drug coverage issues & proactively address, research & resolve issues impacting referral turn-around time. 

• Independently resolve basic patient claims issues using key subject matter knowledge.  

• Prepare and review claims to ensure accuracy to payer requirements, including but not limited to codes, dates, and authorizations.

• Effectively collaborate with internal departments to resolve issues or provide any needed information, always using professional communication.

• Contact benefit providers to gather policy benefits/limitations.  

• Perform medical /pharmacy benefits verification requiring complex decision skills based on payer and process knowledge.

• Complete other projects and additional duties as assigned.  

JOB QUALIFICATIONS:

• High school diploma or GED required, bachelor’s degree preferred

• At least 2+ years of related 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.

• 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.

ABOUT THE DEPARTMENT:

Through our range of health care products and services offered, Accredo team members provide in-depth care for patients with chronic health conditions like hemophilia, oncology, rheumatoid arthritis and growth hormone deficiency. In addition to health care products, we provide comprehensive management services – including outcomes measurement, counseling, clinical care management programs, social services, and reimbursement services. By performing in these very high-touch roles, employees have a daily opportunity to make a positive impact on their patients’ lives.

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 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 predic