Eligibility Senior Representative - Express Scripts - Remote

Express Scripts is currently seeking an Eligibility Senior Representative. The Eligibility Senior Representative performs specialized patient access functions requiring an advanced understanding of insurance benefits and internal processes in order to successfully liaise with Payers, Pharma, Physicians and Patients. This role directly interfaces with external clients and requires a high level of independent judgment and a degree of forward planning and anticipation of needs/issues in order to establish and maintain effective relationships with clients to gain their trust and support. Relies on experience and knowledge of industry best practices to identify exposures to the company and facilitates leadership’s knowledge of pending referrals that may have an adverse impact on company goals and the patient experience. 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.

WORK SHIFT: Monday - Friday, 7a - 4p

RESPONSIBILITIES:

• Facilitate cross-functional resolution of drug coverage issues & proactively address, researches & resolves issues impacting revenue optimization.

• Perform medical /pharmacy benefit verification requiring complex decision skills based on payer and process knowledge resulting in on boarding or no starting a specialty patients.

• Contact benefit providers to gather policy benefits/limitations.

• Coordinate and ensure services provided will be reimbursable (e.g., deductible amounts, co-payments, effective date, levels of care, authorization, etc.).

• Interface with external clients.

• Perform medical /pharmacy benefit verification requiring complex decision skills based on payer and process knowledge resulting in on boarding or no starting a specialty patients.

• Provide expert assistance to clients on patient status.

• Liaison for company providing referral status reporting.

• Negotiate pricing for non-contracted payers and authorize patient services and ensure proper pricing is indicated in Rx Home.

• Handle Escalations.

• Use discretion & independent judgement in handling patient or more complex client complaints, escalating as appropriate.

• Complete other projects and additional duties as assigned.

QUALIFICATIONS:

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

• 3+ years of relevant experience eligibility experience.

• Health care experience with medical insurance knowledge and terminology and experience in patient access preferred.

• Intermediate data entry skills and working knowledge of Microsoft Office.

• Patient Access knowledge.

• Extensive knowledge of ESI products and services a must.

• Experience training and coaching less experienced staff with patience to explain details and processes repeatedly.

• Excellent communication skills. Including phone calls, written, and meeting presentation.

• Demonstrated ability to handle challenging customers in a professional manner.

• 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.

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 r