Claims Representative - EviCore - Remote

The Claims Representative is responsible for reviewing and processing Post Service Medical Necessity Determination (PSMND) claims to ensure accurate adjudication and compliance with benefit plans, policies, and regulatory requirements. This role reviews claim and authorization documentation, including eligibility, benefits, coverage, and authorization requirements; builds and maintains authorization cases; and obtains and attaches clinical documentation to support the medical necessity review process. Following the clinical determination, the Claims Representative adjudicates claims and processes applicable adjustments to ensure accurate and timely resolution. This position does not make medical necessity determinations or authorization approval or denial decisions, which are the responsibility of licensed clinical staff.

Key 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 appropriate clinical documentation for review by clinical staff.
• Process Radiology, Pain Management, Lab, Gastro, and other designated claims in accordance with 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 necessary to support claim resolution.
• Ensure compliance with client requirements, benefit plans, policies, and regulatory guidelines.
• Meet established productivity, quality, and service performance expectations.

Core Competencies Required:

Technical Skills

• Medical terminology knowledge
• CPT and ICD-10 coding knowledge
• Health insurance claims processing experience
• Ability to interpret benefit plans and policy language
• Strong attention to detail and accuracy
• Ability to identify discrepancies and missing information

Technology

• Proficient with Microsoft Office Suite
• Ability to navigate multiple applications simultaneously
• Comfortable working in a virtual environment using Teams, Outlook, Cisco WebEx, and similar tools

Professional Skills

• 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

Qualifications:

• High School Diploma or equivalent required.
• 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.

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

At The Cigna Group, 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), company paid life insurance, tuition reimbursement, a minimum of 18 days of paid time off per year, paid holidays, and leaves of absence. For more details on our employee benefits programs, click here.

About Evernorth Health Services

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 need a reasonable accommodation to complete the online application process, please email seeyourself@thecignagroup.com for assistance. Please note that this email inbox is dedicated to accommodation requests only and cannot provide application updates or accept resumes.

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.

Qualified applicants with criminal histories will be considered for employment in a manner consistent with all federal, state and local ordinances.

About The Cigna Group

Doing something meaningful starts with a simple decision, a commitment to changing lives.

At The Cigna Group, we’re dedicated to improving the health and vitality of those we serve. Through our divisions Cigna Healthcare and Evernorth Health Services, we are committed to enhancing the lives of our clients, customers and patients.

Join us in driving growth and improving lives.