JOB DESCRIPTIONPOSITION : Claims Senior RepresentativeREPORTING TO : Claims Supervisor1. JOB PURPOSEThe job holder is responsible of serving providers and insurance companies by determiningrequirements, answering inquiries, resolving problems, fulfilling requests and maintainingdatabase. He/She is responsible for processing as per terms of benefits. He/She should provideaccurate and relevant medical coverage details and maintain pre-approvals and claims processingas per the defined terms and policies of the organization.2. RESPONSIBILITIES AND DUTIES• Follow Claim Manual and SOP strictly, adjudicate claims according to benefit policies, andmeet both financial/procedure accuracy and TAT target on claims adjudication.• Adjust error claims according to actual situation.• Monitor and highlight high-cost claims and ensure relevant parties are aware.• Well handle recoupment and reconciliation work, communicate with providers andmembers via call and email for collection and explanation.• 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 theorganization.• Achieves required processing targets assigned by the team leader on daily, weekly andmonthly 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 auditscores and NPS (Net Promoter Score).• Assessing and processing claims for medical expenses while always bearing in mind theimportance of medical confidentiality.• Accurate data input to the system applications.• Positioning him/herself analytically and critically in the context of cost management and inrespect of existing working methods.• Following up own workload (volume and timing): keeping an eye on chronology andprocessing time of the work volume and taking suitable actions.• Participate efficiently in processing the flow of claims: inform the supervisor about claimslacking clarity and about possible ways of optimizing the processes.• A sustained effort towards high-quality claims handling, accurate reimbursements and fasttransactions 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, andmeet 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 andmembers via call and email for collection and explanation.• Work with cross function teams, such as Finance, CSR, Eligibility, Network, ClientManagement, etc. Ensure recoupment work go smoothly.• Actively support Team Leader and work with claim colleagues to enable all operationalgoals to be achieved3. KNOWLEDGE, SKILLS AND EXPERIENCE• At least 3-4 years of experience performing a similar role.• Fluent in English.• 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 weekends4. COMMUNICATIONS AND WORKING RELATIONSHIPSThe job holder must ensure building strong effective relationships with all his matrixpartners and demonstrating approachability and openness. He/ She must be able to fosterstrong internal and external communication standards.About The Cigna Group 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.