**This role is WAH/Flex which allows most work to be performed at home. Employees must be fully vaccinated if they choose to come onsite.***

Hours: 9:30am-6:00pm

OVERVIEW

The Claims Advocate - Case Management Analyst position is responsible for representing Cigna Behavioral Health (CBH) to all inbound callers within a call center environment and assuring caller’s contact with CBH is positive. Claims Advocate - Case Management Analysts are generally the first point of contact that customers have with Cigna and thus are responsible for giving a positive first impression.  The Claims Case Management Analyst team has varied tasks that range in complexity and require high level thinking. Also required are exceptional problem solving, the ability to utilize matrix partners from all parts of the Cigna organization, excellent research skills, effective multi-tasking skills and flexibility. 

Being a self-starter is necessary to succeed in this role.  To be most effective, Claims Advocate - Case Management Analysts will need to be experts in understanding benefits and the role of Behavioral Intake as well.  The tasks included in the intake role may include but not limited to: educating customers on benefits, eligibility, referrals, non-clinical resources and assessing for potential risk of harm or substance abuse concerns.

This position services calls in a warm and empathetic manner, as many of the calls are sensitive in nature. Independent problem solving skills are critical to success within the role along with intelligent judgment in assessing the caller’s needs. Based on the call type and requests, Claims Advocate - Case Management Analysts should be able to use their customer service skills, knowledge of mental health/substance abuse and their Cigna training to effectively address caller’s needs.  Incumbents will utilize telephonic communication the majority of the time with some web, and internal CBH materials to achieve first time case resolution for callers.

MAJOR DUTIES   

The primary responsibility of the Claims Advocate - Case Management Analyst is answering calls from customers regarding current behavioral health care services being provided, with particular focus on claims. The majority of the day will be spent answering inbound calls from customers looking to understand how their benefits were applied to their claims, as well as assist customers in obtaining access, understanding, or utilizing services.

Within a call, a Claims Advocate - Case Management Analyst may:

• Assist a member with understanding how their claims have processed.
• Write and/or correct authorizations to ensure claims are paid correctly.
• Outreach health care professionals to clarify concerns related to claims.
• Reprocess claims on the DG platform as well as request reprocessing of claims paid on the Proclaim platform. 
• Educate participants on their benefits based upon individual plan design and other clinical or non-clinical resources available
• Conduct an intake as needed to assess for presenting concern and risk of harm or substance abuse concerns
• Provide participants with names and phone numbers of nearest providers
• Multi-task by maneuvering through various computer programs and screens

As needed Claims Advocate - Case Management Analysts may also:

• Understand and relay the determinations in case notes and provide this to callers.
• Work with Claims Examiners and Claims Examiner Supervisors to determine appropriate next steps and needs for claims to be processed in accordance with customer centric guidelines.
• Utilize the Claims Processing Guidelines (CPGs)
• Provide a direct line of contact for callers regarding claims concerns.
• Provide follow-up calls to participants to ensure correct information is given
• Send eligibility requests to determine effective coverage dates or to verify correct benefits are loaded
• Send complaints to initiate grievance process for customers
• Utilize the OneView queue to send claims back for Proclaim
• Assist with case research offline

On all calls a Claims Advocate - Case Management Analyst is responsible for:

• Providing high quality customer service as identified by Advocacy department quality standards
  • Provide start-to-finish case ownership to ensure complex cases are completed and achieve appropriate resolution even if multiple calls are involved.
• Using independent problem solving skills to make sound decisions in assessing the needs of the callers by giving accurate information and providing first call resolution
• Understanding the larger business needs of Cigna while supporting the needs of the customer.
• Educating callers and helping them navigate the complexities of accessing care and the processing of their claims.
• Demonstrates basic understanding of the responsibilities and workflows of relevant departments within Cigna Behavioral.

Secondary responsibilities that are essential to Claims Advocate - Case Management Analyst’s success may include:

• Completing claims requests in the CRCC Claims mailbox.
• Updating Complex Claim Team tracker to identify issues address in CRCC requests.
• Assist with CRCC Claims requests in a timely manner and following all follow-up guidelines to support matrix partner expectations.
• Assisting less seasoned peers by helping  answer questions
• Participating in staff meetings and in-service seminars
• Initiating tasks in order to make improvements to current workflows that parallel with CBH’s mission.
• Developing an action plan for professional development
• Working with matrix partners, leadership and peer group to help ensure processes are up to date and effective
• Participating in team building activities to  boost morale
• Completing additional assigned projects and tasks
• Maintaining a high level of working knowledge about CBH’s customers and products.

Expectations:

• Must be claims trained with a minimum of 6 months taking claims calls. 
• Actively engage with customers in a positive, professional and empathic manner = 100 % goal
• Provide high quality customer service = no more than six off-target call scores within a full calendar year (pro-rated)
• Follow appropriate workflows and HIPAA guidelines = 100% goal
• Adhere to a pre-determined daily schedule = 92% goal
• Adhere to Cigna Standard Policies regarding absences and lateness.
• Be professional and communicate effectively with internal and external matrix partners = receives consistent positive feedback

QUALIFICATIONS

Required qualifications:

• Bachelor’s degree in mental health field or psychology/social work related field (can also include:  family communications, health coaching, community/public health or other related major). This is a non-clinical role and does not require a license
• Previous customer service experience or related position
• Superb interpersonal communication
• Effective listening and organizational skills
• Ability to manage multiple tasks, setting priorities where needed
• Independently problem solve, with ability to function without constant supervision
• A demonstrated ability to type effectively; with strong PC skills/word processing experience and ability to learn new computer software systems
• Ability to learn new workflows and tasks quickly
• Ability to work  independently and be a team player

Preferred qualifications:

• Leadership skills
• Master’s degree in mental health field or psychology/social work related field
• Previous call center environment experience
• Creative and innovative thinking

This position is not eligible to be performed in Colorado.

About Evernorth

Evernorth, Cigna Corporation’s health services segment, exists to elevate health for all. We're building on our legacy and redefining health care as we know it. Unbiased in how we think, we create without limitation. We partner without constraints, deliver value differently and act in the interest of humanity. Solving across silos, closing gaps in care, and empowering clients, customers, and people everywhere to move onward and upward. When you work with us, you’ll be empowered to solve the problems others don’t, won’t or can’t. Join us. What difference will you make?

Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or related medical conditions including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national origin, ancestry, marital or familial status, genetic information, status with regard to public assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws.

If you require reasonable accommodation in completing the online application process, please email: SeeYourself@cigna.com for support. Do not email SeeYourself@cigna.com for an update on your application or to provide your resume as you will not receive a response.