Job Description

Applicants must reside in one of the following states to be considered for this opportunity: ? Texas, Georgia, Pennsylvania, South Carolina, and Arizona

The Senior Eligibility Representative performs specialized patient access functions requiring an advanced understanding of insurance benefits and internal processes to successfully liaise with Payers, Pharma, Physicians, and Patients. Rely on experience and knowledge of industry best practices to communicate knowledge of pending referrals that may have an adverse impact on company goals and the patient experience. Acts as a liaison between both internal and external resources to reduce client abrasion and facilitate the timely processing of referrals. This individual can proactively recognize cause and effect trends, identify and clarify patients' needs, and work towards solutions.

RESPONSIBILITIES:

• Facilitate cross-functional resolution of drug coverage issues & proactively address, research & resolve issues impacting referral turn-around time.

• Independently resolve basic patient claims issues using key subject matter knowledge.

• Prepare and review claims to ensure accuracy to payer requirements, including but not limited to codes, dates, and authorizations.

• Demonstrate technical proficiency in patient access functions.

• Effectively collaborate with internal departments to resolve issues or provide any needed information, always using professional communication.

• Contact benefit providers to gather policy benefits/limitations.

• Coordinating and ensuring services provided will be reimbursable (e.g., deductible amounts, co-payments, effective date, levels of care, authorization, etc.).

• Perform medical /pharmacy benefits verification requiring complex decision skills based on payer and process knowledge.

• Provide expert assistance to internal and external clients on patient status.

• Handle Escalations with an expert understanding of department policies and procedures.

• Use discretion & independent judgment in handling patient or more complex client complaints, escalating as appropriate and when triaging as needed.

• Complete other projects and additional duties as assigned.

QUALIFICATIONS:

• High school diploma or GED required, bachelor's degree preferred.

• 3+ years of relevant working experience.

• 2 years of Health care experience with medical insurance knowledge and terminology and experience in patient access preferred.

• Intermediate data entry skills and working knowledge of Microsoft Office, and Patient Access knowledge.

• Pharmacy or healthcare industry experience is highly preferred, with prior exposure to Express Scripts (ESI) considered a strong advantage.

• Experienced training and coaching less experienced staff with patience to explain details and processes repeatedly.

• Excellent phone presentation and communication skills.

• Demonstrated ability to handle challenging customers in a professional manner.

• Ability to adapt to a dynamic work environment and make decisions with minimal supervision.

• Advanced problem-solving skills and the ability to work collaboratively with other departments to resolve issues with innovative solutions.

ABOUT THE DEPARTMENT

Through our range of health care products and services offered, Accredo team members provide in-depth care for patients with chronic health conditions like hemophilia, oncology, rheumatoid arthritis and growth hormone deficiency. In addition to health care products, we provide comprehensive management services - including outcomes measurement, counseling, clinical care management programs, social services, and reimbursement services. By performing in these very high-touch roles, employees have a daily opportunity to make a positive impact on their patients' lives.

If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload.

About Evernorth Health Services

Evernorth Health Services, a division of The Cigna Group, creates pharmacy, care and benefit solutions to improve health and increase vitality. We relentlessly innovate to make the prediction, prevention and treatment of illness and disease more accessible to millions of people. Join us in driving growth and improving lives.

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 need a reasonable accommodation to complete the online application process, please email [email protected] for assistance. Please note that this email inbox is dedicated to accommodation requests only and cannot provide application updates or accept resumes.

The Cigna Group has a tobacco-free policy and reserves the right not to hire tobacco/nicotine users in states where that is legally permissible. Candidates in such states who use tobacco/nicotine will not be considered for employment unless they enter a qualifying smoking cessation program prior to the start of their employment. These states include: Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Georgia, Hawaii, Idaho, Iowa, Kansas, Maryland, Massachusetts, Michigan, Nebraska, Ohio, Pennsylvania, Texas, Utah, Vermont, and Washington State.

Qualified applicants with criminal histories will be considered for employment in a manner consistent with all federal, state and local ordinances.

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