Appeals Processing Sr. Representative - Evernorth - Remote

This role is responsible for reviewing and resolving medical claims appeals submitted by customers, clients, and healthcare professionals. The Appeals Processing Sr. Representative researches claim decisions against established payment guidelines, internal procedures, and regulatory requirements to determine whether claims were processed correctly or require adjustment. Responsibilities Review incoming Appeals from Customers, Clients and HealthCare Professionals Research item being appealed against Standard Operating Claim Payment Procedures and/or State and Federal Regulations in IComply, and Benefit Access Determine if the claim issue in question was paid correctly or needs an adjustment Adjust overturned appeals or appropriately route the appeal for adjustment Manage personal inventory and aging by use of daily reports provided Prepare and route appeals requiring clinical review to the Clinical Appeals Team Create and issue documentation explaining appeal decision Qualifications High School Diploma or equivalent required Proclaim/Facets systems, OneView and iView knowledge is preferred Able to manage multiple tasks and work under pressure in a fast paced environment Excellent verbal and written communication skills Strong attention to detail and the ability to work in multiple systems concurrently Strong organization and time management skills; effectively adapts to multiple and/or competing priorities Process improvement skills; ability to assess trends, processes and bar