The Government Business Segment Cost Avoidance and Recoveries Operations Senior Claims Representative Cost Avoidance - Pre Pay is a role within the Cigna Medicare Customer & Client Service Experience Organization. This role is responsible for working with the Cost Avoidance and Recovery internal teams, as well as participating in multiple vendor relationships. The Senior Claims Representative Cost Avoidance - Pre Pay adheres to proper application of coding and audit policies in accordance with CMS and Medicare payment methodology and compliance, provider contracts, and internal business rules.  The role assists a team that supports transactions and disputes associated with cost avoidance edits.

It also includes working with internal staff and the vendors to resolve and track provider disputes related to cost avoidance, system issues, IT processes, and provider contracts as well as working with external suppliers to increase edits and improve the accuracy of savings & recovery identified.

Responsibilities:

• Works in conjunction with multiple vendor relationships with the ability to handle additional vendors as the Government Business Segment grows.
• Assist with implementations related to new vendors for cost avoidance pre-payment/post-payment edits, subrogation
• Participate in Implementation of vendor services for new markets or existing Cigna plans
• Implement new audits and edits to increase and maximize overall savings
• Participates in workgroups to help resolve complex payment issues; involving QNXT/QCARE Configuration, Health Services, Network, and Contracting 
• Collaborates with counterparts from the Cigna Commercial (ClaimsXten, ClaimCheck, Prepayment editing)
• Assists with training of team members and External Vendors
• Ability to interpret coding guidelines, CMS regulations, reimbursement, Medicare Claim Processing for accurate application of policy to claim edits and audits
• Research coding and fee schedule questions supporting various departments: Network Operations, Provider Contracting and Configuration
• Review unsettled provider disputes for compliant and fair outcome utilizing Call Trackers
• Participates in the review and approval process of new Medicare coding edits for claims 
• Assist manager/supervisor with Legal questions, issues related to edits, audits and reimbursement
• Review monthly reports from Suppliers; addressing trends, concerns, spikes or actionable items

Qualifications:

• Bachelor’s degree preferred or equivalent experience
• 5+ years Medicare Advantage experience in cost avoidance arena
• Certified Coding Specialist (CCS) or Certified Coding Professional (CPC) preferred or 5+ years practical experience in inpatient coding/DRG, CPT and ICD10 coding, with extensive knowledge of all CMS Prospective Payment systems with ability to apply knowledge in the payer environment (willingness to obtain certification in 1-2 years)
• Knowledge of Call Tracker Process and Impact to Business a plus
• Knowledge of Medicare Advantage, Prescription Drug Plans, and Medicaid regulations a plus
• Experience serving on a configuration team as the SME (Subject Matter Expert), with proven ability to effectively communicate with all levels of the organization, including technical staff, internal non-technical staff, testing teams, all Market leads.
• Proficiency in medical terminology, medical coding (CPT4, ICD10, and HCPCS), provider contract concepts and common claims processing/resolution practices.
• Proficient in Microsoft Office including Outlook, Word, Excel, and PowerPoint.
• Claims Processing Experience (Prefer QNXT/QCARE systems)
• Complete Market projects that need to be worked and responded to timely 
• Monitor for Medicare and Medicaid payment and policy changes and ensure they are researched for potential configuration and savings.  Analyze CMS/AMA Policy Guidelines, ICD 10 guidelines, and Vendor Reporting  
• Experience gathering and communicating Policies and Procedures in a simple and easy to understand manner to other team members/management. Document criterion to determine best method of workflow, research and execution
• Complete assigned tasks and/or oversee the completion of those tasks within timelines 
• Prepare Monthly Savings/Recovery summaries for management and meetings
• Understand Center for Medicare/Medicare Services (CMS) claims editing policies  
• Utilize knowledge of areas related to Claims, e.g. Network Operations, Claims Processing, Pre and Post Pay Vendors, Cost Avoidance and Recovery team members  
• Demonstrated ability to work independently on multiple projects and priorities 
• Strong, independent decision-making ability
• Complete other projects and duties as assigned  

This role is a Work from home (WFH) role which allows most work to be performed at home. Employees must be fully vaccinated if they choose to come onsite.

This position is not eligible to be performed in Colorado.

About Cigna

Cigna Corporation exists to improve lives. We are a global health service company dedicated to improving the health, well-being and peace of mind of those we serve. Together, with colleagues around the world, we aspire to transform health services, making them more affordable and accessible to millions. Through our unmatched expertise, bold action, fresh ideas and an unwavering commitment to patient-centered care, we are a force of health services innovation. When you work with us, or one of our subsidiaries, you’ll enjoy meaningful career experiences that enrich people’s lives. 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.