Career Opportunities at Cigna

Role Purpose

Responsible to review and approve medical services requested by providers or customers according to medical necessity review guidelines. Will ensure customers receive the best quality care, diagnostics and treatment and avoid over or under-utilization of clinical services. Ability to review, investigate and respond to external and internal inquiries/complaints. Provide guidance to other clinical and non-clinical staff related to medical necessity.

• Part of a clinical team that provides medical management services to customers worldwide but mainly in Africa region.
• Give evidence-based advice on pre-authorization, considering internationally accepted protocols and local and/or regional customs and regulations.
• Assessing pre-authorization requests claims in line with the policy coverage and medical necessity. 
• Identify and refer cases to the Cigna Clinical team for case management, disease management and other clinical services 
• Assist and support the team in cost containment, assist in projects and service delivery to meet goals. 
• To assist queries from providers and payers via phone calls or e-mails 
• Be fully versed with medical insurance policies for various groups / beneficiaries. 
• Might be required to assist in training colleagues and sharing knowledge. 
• Ability to review, investigate, and respond to external and internal inquires/complaints and provide guidance to other clinical and non-clinical staff related to medical necessity. 
• Assist in fraud detection
• Meeting the defined qualitative and quantitative key performance metrics for the assigned job role. 
• Ensure adherence to the predefined TATs for pre-approvals 
• Achieving required targets assigned by the team leader on daily, weekly, and monthly basis. 
• Ensure compliance to any changes in terms of system parameters or process. 
• Other duties as assigned.

REQUIREMENTS

• University Degree or Diploma in Medical specialization . 
• 2-3 years of clinical experience preferable in a payer setting on medical management.
• Experience in the Africa region & International market
• Fluent in English along with either French, Portuguese or Spanish, any other language is a plus
• Strong interpersonal and communication skills. 
• Must be a computer literate
• Knowledge of utilization, cost containment services, insurance coverage.
• Ability to build solid working relationships with staff, clients, customers, and healthcare providers. 
• Demonstrates pro-active problem-solving and analytical skills 
• Ability to work under pressure and meet tight deadlines 
• Flexible to work on shifts/varying work schedules.

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Role Purpose

Responsible to review and approve medical services requested by providers or customers according to medical necessity review guidelines. Will ensure customers receive the best quality care, diagnostics and treatment and avoid over or under-utilization of clinical services. Ability to review, investigate and respond to external and internal inquiries/complaints. Provide guidance to other clinical and non-clinical staff related to medical necessity.

Your Job

• Assess and process medical approvals using the company system in accordance with conditions & terms of medical policies.
• Give evidence-based advice on preauthorization and medical claims considering internationally accepted protocols and local and or regional customs and regulations. Will use Cigna coverage policy and MCG guidelines.
• Identify and refer cases to the clinical programs team for case management, disease management and other clinical services and assure quality of performance against QA standards to promote optimal service delivery. Give appropriate corrective action if necessary.
• To assist queries from providers and payers via phone calls or e-mails.
• Ensure that hospitals worldwide receive expertise advisory and all necessary documents for a plan member's admission within the best possible terms.
• Undertaking of hospital admission approvals and declines.
• Ensure appropriate Turnaround Time is adhered to in issuing inpatient and outpatient guarantee of payment approvals.
• Seeking medical clarifications including medical reports, copies of investigation reports, etc.
• Maintain relations by communicating all necessary admission guarantee of payment decisions on a timely basis.
• Ensuring guarantee of payments undertakings are issued in line with the policy provisions. Likewise for declines, ensuring that the decisions are accurate and a correct interpretation of the policy.
• Work with the provider claims reviewers for inpatient claims and coordinating on any information noted in the inpatient claim submitted especially in cases where further information provided changes the position undertaken previously on the claim.
• Interacting with clients, brokers and clinicians as needed, to resolve problems in a manner that is legal, ethical, and consistent with the principles of the policy.
• Checking and confirming membership validity and benefits from policy documents.
• Vetting and confirming validity of the service given by the service provider in relation to the benefits covered, treatment given, adherence to provider panel rules and cost of treatment.
• Obtaining additional required information on claims from providers, brokers, or clients.
• Liaising with our eligibility section on scope of cover for various contracts.
• Training new colleagues in the team.
• You organize the in- and outflow of all incoming communication with special attention to the quality of the messages and to the response turnaround times.
• All of these tasks are performed in English or other languages. French, Portuguese or Spanish an added advantage.

YOUR PROFILE

Qualifications

• Medical related degree or Diploma
• Healthcare/insurance experience or professional qualification is a plus
• Proficient in the use of Microsoft Office Suite and packages

Relevant Experience

• You have 2-3 years of clinical experience preferably in a hospital setup or insurance medical management, case management, disease management programs and tools are an advantage.
• You have knowledge of utilization, cost containment services, and insurance coverage.
• You are flexible to work on shifts/varying work schedules.
• You  work accurately and have ability to work under pressure and meet tight deadlines.
• You are strong in communication.
• You are service-minded.
• You have a strong sense of responsibility.
• You can easily handle procedures regarding document verification.
• You can easily work with several software applications. simultaneously.
• You are analytical and like taking initiative.
• You handle confidential information in a discrete manner.
• You work autonomously but also enjoy working as part of a team.

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What are your main responsibilities?

• You are responsible for the client communication for designated account relationships and Contracts.
• You are required to response to the client on timely manner providing full and accurate information in one go.

Main Duties / Responsibilities

• Handle calls and e-mails and respond to simple and complex inquiries regarding eligibility, cards status, envoy registration/navigation, policy benefits, issue certificates of insurance, claims status and other related information and provide solutions for customers and clients.
• Receives requests by mail, telephone, or in person regarding insurance claims/policies. Responds to inquiries from policy holders, clients, brokers and/or others.
• Performs research to respond to inquiries and interprets policy provisions to determine most effective response.
• Mails or routes claim forms and supporting documentation to various units for final processing.
• Excellent interpersonal skills, ability to understand and interpret policy provisions. Independently responds to inquiries, grievances, complaints, or appeals ranging from routine to moderate complexity.
• May seek assistance with complex customer services issues.

Qualifications

• Must have a diploma or bachelor’s degree certificate
• Excellent English written and oral communication skills
• Portuguese written and oral skill is a must
• Exceptional organizational and time-management focus
• Independently responds to inquiries, grievances, complaints or appeals ranging from routine to moderate complexity.
• 1+ years of customer service experience analyzing and solving customer problems required; call center experience a plus
• Ability to perform in a high volume, fast paced call center environment
• Proven ability to work independently as well as a productive member of a team
• Intermediate proficiency in Microsoft office suite; high level capacity to multitask independently and on a computer
• Knowledge of medical terminology a plus