Customer Service Lead Representative - Cigna Healthcare - Remote

The Grievance team manages Cigna Healthcare Medicare/ Medicaid grievances that are presented by our member’s or their representatives pertaining to the authorization of or delivery of clinical and non-clinical services. Grievance works in collaboration with divisions within and outside the organization to resolve issues in a timely and compliant manner.

The Quality Review Coordinator is responsible for performing Internal Quality Review Audits of operational processes for Intake, Research and Resolution to ensure compliance with policies, procedures and quality standards. The reviewer will investigate, audit, conduct root cause analysis, handle processing of determinations, track and trend findings. The individual at this level will embody Cigna’s Culture Drivers through his/her workplace behavior and will work under minimal supervision.

Duties and Responsibilities:
Conduct quality audits of grievances, appropriate sources of information; including eligibility, claims, authorizations, service forms, faxes, and any additional information required to complete all grievance investigations. Analyze errors and determine root causes for appropriate classification, trending, and remediation.
Record/track quality assessment scores and provide feedback to reduce errors and improve processes and performance to ensure quality.
Review and investigate grievance request to ensure all requests are identified, classified, and fully resolved in a compliant manner.
Present results of investigations to senior staff and prepare written reports concerning investigation activities.
Subsequent auditing and handling of grievance requests including processing where applicable, tracking, documenting, reporting and dispersal of findings and recommendations.
Identify defects and improve departmental performance by supporting quality, operational efficiency and production goals.
Assist in the development of departmental policies and procedures; reviews the efficiency of existing training.
Meet established time frames and rates of performance for the quality and quantity of work for the position.
Participate in regulatory and mock audit activities including universe review, universe scrubbing, risk analysis, timeliness assessment, and case walkthrough activities.
Additional duties as assigned

Schedule :
Mon.-Fri. 8am-5pm (Local time zone)
Must be available to work rotating Saturdays

Candidate Qualifications
2+ years' experience in a Medicare, Medicaid managed care environment, customer service or grievances
High school diploma or GED required.
Experience in an Auditing capacity conducting root cause analysis
Experience in clinical practice with experience in appeals & grievances, claims processing, utilization review or utilization management/case management
Experience handling confidential information.
Compliance & Regulatory Responsibilities: Knowledge of state and federal appeal and grievance regulatory requirements
Strong written and verbal communication skills, a bility to work independently on several computer applications such as Microsoft Word and Excel, as well as corporate email
Demonstrated ability to manage large caseloads and effectively work in a fast-paced environment.

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.

For this position, we anticipate offering an hourly rate of 19 - 29 USD / hourly, depending on relevant factors, including experience and geographic location.

This role is also anticipated to be eligible to participate in an annual bonus plan.

We want you to be healthy, balanced, and feel secure. That’s why you’ll enjoy a comprehensive range of benefits, with a focus on supporting your whole health. Starting on day one of your employment, you’ll be offered several health-related benefits including medical, vision, dental, and well-being and behavioral health programs. We also offer 401(k) with company match, company paid life insurance, tuition reimbursement, a minimum of 18 days of paid time off per year and paid holidays. For more details on our employee benefits programs, visit Life at Cigna Group .

About Cigna Healthcare
Cigna Healthcare, a division of The Cigna Group, is an advocate for better health through every stage of life. We guide our customers through the health care system, empowering them with the information and insight they need to make the best choices for improving their health and vitality. 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 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.

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.