Claim representative

JOB DESCRIPTION   POSITION               : Claim Representative A REPORTING TO      : Claim Supervisor or Manager DEPARTMENT       : Claims Career Band          : Band 1     About US At CIGNA Healthcare we are guided by a common purpose to help make financial lives better through the power of every connection. Responsible Growth is how we run our company and how we deliver for our clients, teammates, communities, and shareholders every day. One of the keys to driving Responsible Growth is being a great place to work for our teammates around the world. We are devoted to being a diverse and inclusive workplace for everyone. We hire individuals with a broad range of backgrounds and experiences and invest heavily in our teammates and their families by offering competitive benefits to support their physical, emotional, and financial well-being. CIGNA Healthcare believes both in the importance of working together and offering flexibility to our employees. We use a multi-faceted approach for flexibility, depending on the various roles in our organization.   Working at CIGNA Healthcare will give you a great career with opportunities to learn, grow and make an impact, along with the power to make a difference. Join us!   JOB PURPOSE The job holder is responsible of serving providers and insurance companies by determining requirements, answering inquiries, resolving problems, fulfilling requests and maintaining database. He/She is responsible for processing as per terms of benefits. He/She should provide accurate and relevant medical coverage details and maintain pre-approvals and claims processing as per the defined terms and policies of the organization.     RESPONSIBILITIES AND DUTIES • 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 r