Summary: The Eligibility Representative performs specialized patient access functions requiring an advanced understanding of insurance benefits and internal processes in order to successfully liaise with Payers, Pharma, Physicians and Patients. This role directly interfaces with external clients and requires a high level of independent judgment in order to establish and maintain effective relationships with clients to gain their trust and support. Relies on experience and knowledge of industry best practices to identify exposures to the company and facilitates leadership’s knowledge of pending referrals that may have an adverse impact on company goals and the patient experience. Acts as a liaison between both internal and external resources to reduce client abrasion, facilitate the timely processing of referrals and provide accurate status reporting to clients.

Responsibilities:

• Facilitates cross-functional resolution of drug coverage issues & proactively address, researches & resolves issues impacting revenue optimization.
• Performs medical /pharmacy benefit verification via internal patient management tracking tools based on payer and process knowledge resulting in on boarding or no starting a specialty patients.
• Contacts benefit providers to gather policy benefits/limitations.
• Coordinating and ensuring services provided will be reimbursable (e.g., deductible amounts, co-payments, effective date, levels of care, authorization, etc.).
• Proactively ensure shipments clear according to insurance criteria, ensuring reimbursement and minimizing risk of bad debt
• Performs medical /pharmacy benefit verification requiring complex decision skills based on payer and process knowledge resulting in on boarding or no starting a specialty patients.
• Provide expert assistance to clients on patient status.
• Liaison for company providing referral status reporting with external clients
• Demonstrated ability to handle challenging customers in a professional manner.
• Use discretion & independent judgement in handling patients or more complex client complaints, escalating as appropriate.
• Completes other projects and additional duties as assigned.
• This role may have incoming and outgoing calls each day amounting to 30% to 50% of the day.

Qualifications:

• High school diploma or GED required, bachelor’s degree preferred.
• 2+ years of relevant working experience.
• Health care or professional office experience with medical insurance knowledge and terminology preferred.
• Advanced problem solving skills and the ability to work collaboratively with other departments to resolve issues with innovative solutions.
• Proven 'attention to detail skills' are required.
• Intermediate data entry skills and working knowledge of Microsoft Office Suites.
• Excellent phone presentation and communication skills.
• Interest and curiosity to learn new skills in a changing environment
• Ability to adapt in a dynamic work environment and make decisions with minimal supervision.
• Advanced problem solving skills and the ability to work collaboratively with other departments to resolve issues with innovative solutions.
• Candidates must live on the island of Oahu

This is a hybrid role and will require the ability to work in person.

* * *This is a hybrid position where the candidate will be REQUIRED to come into the 677 Ala Moana Blvd, Suite 404, Honolulu, HI 96813 office 2 times per week. * * *

If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload.

For this position, we anticipate offering an hourly rate of 19 - 29 USD / hourly, depending on relevant factors, including experience and geographic location.

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

Evernorth Health Services, a division of The Cigna Group, creates pharmacy, care and benefit solutions to improve health and increase vitality. We relentlessly innovate to make the prediction, prevention and treatment of illness and disease more accessible to millions of people. Join us in driving growth and improving lives.

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 [email protected] 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.