Claims Representative
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Job Description
Claims Representative reviewing and adjudicating post-service medical necessity claims for Evernorth Health Services. Verifying coverage, managing authorization documentation, and resolving claim discrepancies remotely.
Responsibilities:
- Review medical records, authorization documentation, and claim information to support post-service medical necessity reviews
- Verify member eligibility, benefits, coverage, authorizations, and claim requirements
- Build and maintain authorization cases and attach clinical documentation for review by clinical staff
- Process Radiology, Pain Management, Lab, Gastro, and other designated claims according to established policies and procedures
- Adjudicate claims and process claim adjustments based on authorization and clinical review outcomes
- Research and resolve claim discrepancies, missing information, and pending claim inventories
- Create and manage ECRM tickets and other operational workflows supporting claim resolution
- Ensure compliance with client requirements, benefit plans, policies, and regulatory guidelines
- Meet established productivity, quality, and service performance expectations
- Review and process Post Service Medical Necessity Determination claims; the role does not make medical necessity determinations or authorization approval or denial decisions
Requirements:
- High School Diploma or equivalent required
- Medical terminology knowledge
- CPT and ICD-10 coding knowledge
- Health insurance claims processing experience
- Ability to interpret benefit plans and policy language
- Proficiency with Microsoft Office Suite
- Ability to navigate multiple applications simultaneously
- Comfortable working in a virtual environment using Teams, Outlook, Cisco WebEx, and similar tools
- Strong attention to detail and accuracy
- Ability to identify discrepancies and missing information
- Self-motivated and accountable
- Strong time management
- Adaptability and growth mindset
- Effective written and verbal communication
- Ability to meet productivity and quality KPIs
- Customer-focused service delivery
- Working knowledge of medical claims processing, provider issue resolution, and healthcare operational workflows preferred
- Experience utilizing MC400, ICE, NASCO, ImageOne, Outlook, Microsoft Excel, and Microsoft Word a nice to have
- Knowledge of medical terminology and CPT/ICD-10 coding preferred
- Proven ability to work collaboratively across operational, provider, program, and client-facing teams
- Demonstrated ability to manage multiple priorities while maintaining quality and productivity standards
- If working from home, cable broadband or fiber optic internet service with at least 10Mbps download/5Mbps upload required
Benefits:
- Annual bonus plan eligibility
- Medical, vision, and dental benefits starting on day one
- Well-being and behavioral health programs
- 401(k)
- Company-paid life insurance
- Tuition reimbursement
- Minimum of 18 days of paid time off per year
- Paid holidays
- Leaves of absence
- Remote work arrangement
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