Cigna Bedford , TX 76021
Responsible for handling member and provider appeals/complaints involving medical necessity, retroactive authorizations, prescription drug coverage, and/or member eligibility. Responsible for tracking and reporting performance against HHSC guidelines. May complete intake, initialize the case for processing, and ensure cases are completed in a quality, organized, and timely fashion.
Essential Duties and Responsibilities:
Responsible for intake of appeals/complaint unit mail, sorting, and distributing within required timeframes.
Responsible for date stamping and properly identifying request type and region. Utilizes appropriate system to research required documentation for case work up.
Responsible for determining the appropriate type of response to a requested appeal or complaint.
Must determine deadline dates on all cases and ensure they are met or exceeded.
Contacts parties to obtain missing/outstanding information for processing and completion.
Prepares all correspondence to gather and investigate a case.
Obtains waivers of liability (WOL), authorization of representative (AOR), and medical records requests.
Refers cases to other departments to gather information to complete the investigation.
Maintains tracking and monitoring information on a database and software used in the department.
Provides tracking and trending reports to departmental leadership on the root causes of appeals and complaints and the high volume appellants.
Responds to Expedited and Provider Claim appeals.
Keeps current with all requirements of STAR PLUS plan appeals and complaints.
Provides training to peers as necessary in case handling.
Enters all job related activities in the applicable database
Knowledge, Skills, Abilities Required:
Comprehensive knowledge in STAR PLUS Appeals and Complaints and experience in managed care
Strong analytical skills, ability to formulate, write reports and professional correspondence
Knowledge of regulations and statutory language and interpretation
Understanding of the claims, membership and health services systems
Strong sense of customer service.
Excellent verbal and written communication skills.
Strong interpersonal skills including tact, diplomacy, and flexibility to work effectively with senior administration, staff and general public.
High School Diploma or Equivalent
Knowledge and Proficiency with Microsoft Office
Strong data entry skills