Appeals Processing Senior Representative - Evernoth - Remote

The Cigna Group

10d•$19 - $29•Remote

About The Position

The Clinical Coder conducts outpatient post-service administrative claims or appeals coverage determinations (such as bundling reviews) for which they are empowered outside of our company's clinical unit manager program requirements. This role applies all benefit plan limitations or exclusions and applicable federal and state regulatory requirements to each case review, including Patient Protection and Affordable Care Act. The Clinical Coder also keeps all HIPAA regulatory requirements. This role is for a Medical Coder; not Appeals Processing.

Requirements

High school education or GED required.
Required coder certification; only accepted for 2 programs: AAPC (American Academy of Professional Coders): CPC (Certified Professional Coder) or AHIMA (American Health Information Management Association): CCS-P (Certified Coding Specialists-Physician based). Note: Apprentice stage of certification is not eligible.
Good research and analytic skills per employee work history.
Proven ability to work independently.
Demonstrated good judgment.
Proven detail orientation
Strong organizational skills
Strong knowledge in medical terminology, anatomy and physiology.

Nice To Haves

1 + year experience CPT-4 and ICD-9/ICD-10 coding experience preferred.
Familiarity with state and federal regulations preferred.
Greater than 2 years’ experience in billing, claims, customer service, or health insurance preferred.

Responsibilities

Makes coverage determinations only on retrospective administrative OP claims/appeals such as bundling reviews using standard NAO and claims policies and procedures and company administrative guidelines.
Research claims and appeals information, submitted review request letters or referrals and related materials in order to make coverage determinations on retrospective OP claims/appeals such as bundling reviews.
Accurately screens any claim referral or appeal subject to state or federal mandates in order to correctly make coverage determinations on retrospective administrative outpatient claims/appeals such as bundling.
Confirms appeal set up to meet state regulatory requirements on non-ASO appeals.
Communicates approval or denial determinations made on retrospective administrative outpatient claims/appeals such as bundling reviews as required.
Documents all retrospective administrative OP claims/appeals such as bundling reviews in the appropriate unit manager and appeals/calls systems as directed by the National Appeals Organization (NAO) policies and procedures.
Manages assigned workload to completion within timeliness metrics as set forth by ERISA, state mandates, PPACA, NCQA and URAC.
Completes all required training per regulatory and credentialing body standards.
When requesting protected health information (PHI) from external or internal sources, employee limits requests for information to reasonably necessary information required to accomplish the intended purpose; accesses the minimum necessary amount of protected health information (PHI) needed to perform job functions; limits the health information disclosed to the amount reasonably necessary for its intended purpose on all routine or recurring disclosures of protected health information (PHI).