Medicare Appeals Processing Senior Representative - Cigna ...

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Requirements:

• Minimum High School Diploma required; prefer medical assistant or Medicare Claims background.
• 3+ years' experience in Medicare Advantage or related healthcare settings.
• Good knowledge of Appeals Processing and operational procedures.
• Understanding of Medicare Advantage, Original Medicare, and Medicaid regulations.
• Strong written and oral communication skills.
• Ability to provide fact-based answers and clear documentation.
• Proficient in Microsoft Office (Access, Excel, PowerPoint, Word).
• Ability to prioritize workflow, apply HIPAA and CMS guidelines, and meet turnaround times.
• Detail-oriented with critical thinking skills.
• Familiarity with systems like MHK, Facets, OneView, QNXT.

Responsibilities:

• Conduct detailed investigation of appeal documents and enter data correctly into the system.
• Communicate proactively with appellants, leadership, providers, and case managers.
• Support the Medicare appeals launching process.
• Retrieve and classify assigned cases based on issue analysis.
• Validate all assigned cases and review appeal documents.
• Assign priority and due dates based on regulations.
• Monitor reports and follow up for necessary information.
• Conduct non-clinical appeals reviews and validate information accuracy.
• Document and enter data in applications, ensuring adherence to workflows and policies.
• Report trends and areas of opportunity to management.