Health Claims Examiner - Cigna Healthcare - Remote

The Claims Examiner is responsible for the accurate and timely processing of medical, dental, vision and prescription drug claims. The incumbent is expected to provide courteous and prompt responses to customer inquiries.

The incumbent is expected to communicate professionally with peers, supervisors, subordinates, vendors, customers, and the public, and to be respectful and courteous in the conduct of this position.

Essential job functions include the following. Other functions may be assigned as business conditions change.

• Verifies the accuracy and receipt of all required documentation for each claim submitted.
• Collaborates with providers, plan participants, other claims payers, or any other party necessary to obtain information necessary to accurately process a claim.
• Analyzes information necessary for processing. This includes, but is not limited to, general participant and provider information, managed care affiliation, diagnosis codes, dates, place, type of service, procedure codes, and charges.
• Assures that the system processes the claim correctly and determines payment according to the plan as written.
• Word‑processes correspondence to plan participants and providers in reference to pre‑determinations and in response to basic benefit questions.
• Answers telephone calls from plan participants, group contacts, and customer service representatives pertaining to benefits and claims inquiries.
• Resolves problematic claims with the assistance of the Team Leader, Claims Manager and/or the Director of Claims.
• Assigns critically ill patients to large case management. Assists the case manager with direct negotiation and the efficient use of benefits.
• Assists other examiners as needed due to workload requirements, including assigned back‑up when examiners are absent.
• Aids the Team Leader and/or the Claims Manager in the resolution of claim appeals and disputes by providing documentation for review.
• Researches, calculates and requests refunds when necessary.
• Contributes to the daily workflow with regular and punctual attendance.
• Thoroughly researches and completes renewal reports in a timely manner in consultation with the Marketing Department.
• Process eligible claims on groups before the end of their stoploss contract renewal period.
• Assists the Legal Department with subrogation claims as necessary.
• Attends various group meetings as required.
• Assists with audits as needed.
• Assists with plan benefit set‑up and changes as needed.

1+ year of LUMINX Processing experience is required

High school graduation or GED required.

• Excellent oral and written communication skills required.
• PC skills, including Windows and Word. Ability to learn all functions of the claims processing software as is necessary for claims processing and adjudication. Must be able to adapt to software changes as they occur.
• Typing ability of 45 wpm net.
• Excellent listening skills.
• Basic mathematical skills.
• High level of interpersonal skills to work effectively with others.
• Ability to organize and recall large amounts of detailed information.
• Ability to read, analyze and interpret benefit summary plan descriptions, insurance documents, plan benefits, and regulations and make appropriate applications to specific situations.
• Ability to meet productivity standards with 99% financial accuracy and 95% procedural accuracy.
• Thorough knowledge of claims processing procedures and requirements.
• Ability to project a professional image and positive attitude in any work environment.
• Ability to comply with privacy and confidentiality standards.
• Ability to be flexible, work under pressure and meet deadlines.
• Ability to analyze and solve problems with professionalism and patience, and to exercise good judgment when making decisions.
• Ability to operate typical office equipment.
• Working knowledge of general office procedures.

Since 1981, Allegiance by Cigna Healthcare has specialized in the administration of medical benefits, offering core services such as claims processing, customer service, utilization management, and case management. Backed by a unique high‑touch approach to both member and client…