Claims Representative

• Processes claims from members and providers.
• Assists queries from providers and payers via phone calls or e-mails.
• Maintains files for authorizations and other reports.
• Assesses and processes claims in line with the policy coverage and medical necessity.
• Be fully versed with medical insurance policies for various groups / beneficiaries.
• May assist in training colleagues and asked to share knowledge.
• Accurately assesses eligibility within the policy boundaries.
• Monitors and maintains the claims processing as per the defined terms and policy of the organization.
• Achieves required processing targets assigned by the team leader on daily, weekly and monthly basis.
• Monitors the qualitative and quantitative measures for claims & pre-approvals.
• Ensures compliance to any changes in terms of system parameters or process.
• Maintains quality as per framework for accuracy.
• Maintains productivity and responsiveness to the work allocated.
• Collaborate with other stakeholders / teams to resolve queries including complex queries.
• Actively support all team members to enable operational goals to be achieved.
• Meet or exceed Service Level Agreement requirements, team KPI(s), monthly quality audit scores and NPS (Net Promoter Score).
• Assessing and processing claims for medical expenses while always bearing in mind the importance of medical confidentiality.
• Accurate data input to the system applications.
• Positioning him/herself analytically and critically in the context of cost management and in respect of existing working methods.
• Following up own workload (volume and timing): keeping an eye on chronology and processing time of the work volume and taking suitable actions.
• Participate efficiently in processing the flow of claims: inform the supervisor about claims lacking clarity and about possible ways of optimizing the processes.
• A sustained effort towards high-quality claims handling, accurate reimbursements and fast transactions are important motivators.
• Monitor and highlight high-cost claims and ensure relevant parties are aware.
• Follow Claim Manual and SOP strictly, adjudicate claims according to benefit policies, and meet both financial/procedure accuracy and TAT target on claims adjudication.
• Adjust error claims according to actual situation.
• Well handle recoupment and reconciliation work, communicate with providers and members via call and email for collection and explanation.
• Work with cross function teams, such as Finance, CSR, Eligibility, Network, Client Management, etc. Ensure recoupment work go smoothly.
• Actively support Team Leader and work with claim colleagues to enable all operational goals to be achieved

• At least 1-2 years of experience performing a similar role.
• Experience of working for an international company, preferred but not essential.
• Claims processing or insurance experience, preferred but not essential.
• Broad awareness of medical terminology, advantageous.
• Excellent organizational skills, capable of following and contributing to agreed procedure.
• Strong administration awareness and experience, essential.
• Strong skills in Microsoft Office applications, essential.
• First class written and verbal communication skills, essential.
• Ability to communicate across a diverse population, essential.
• Capable of working independently, or as part of a team.
• Good time management, ability to work to tight deadlines.
• Flexible and adaptable approach, sometimes working in a fast-paced environment.
• Passion for achieving agreed objectives.
• Confident in calling out when facing issues.
• Should be flexible to work in shifts and on staggered weekends for overtime.

The Cigna Group