Job Summary
This role focuses on delivering high-quality customer service for health care clients through responsive case handling and accurate documentation while working from home during day shifts. The position involves using MS Excel to track appeals and grievances efficiently supporting process transparency and continuous improvement that enhances member satisfaction and contributes to more reliable health care outcomes.
Responsibilities
- Responsible for reviewing and adjudicating pharmacy appeals submitted through an external portal in accordance with state-specific requirements and guidelines.
- Validates claim and adjudication details, including drug/NDC information, quantity, pricing, and supporting documentation to ensure accuracy and completeness.
- Investigates and resolves exceptions such as invoice discrepancies, NDC mismatches, incomplete submissions, and corrupted or missing documentation through direct communication with pharmacies.
- Determines appeal outcomes by granting or denying requests based on established criteria and supporting evidence.
- For approved appeals, creates adjustment requests and cases with detailed instructions to facilitate claim reversal and reprocessing, ensuring pharmacies receive accurate reimbursement.
Daily Responsibilities:
- Handle incoming customer inquiries with calm and structured communication ensuring that each interaction is documented accurately and resolved within agreed timelines while working from home during day shifts.
- Manage case records in MS Excel by maintaining detailed logs of customer requests appeals and grievances enabling clear visibility of case status for internal teams and contributing to reliable reporting.
- Update and organize spreadsheets with standardized formats for customer service metrics such as response times and resolution rates supporting data driven decisions that improve service quality.
- Collaborate with internal operations and clinical support teams through virtual channels to clarify case details align on next steps and ensure every customer concern is addressed thoroughly and consistently.
- Escalate complex service issues using defined procedures providing clear written summaries that help specialist teams evaluate appeals or grievances efficiently and fairly.
- Monitor daily work queues and prioritize cases based on urgency and impact ensuring that time sensitive appeals and grievances are handled promptly to protect member trust and satisfaction.
- Verify completeness of customer information and supporting documents in MS Excel trackers reducing errors and rework while helping the organization meet compliance and audit expectations in the health care domain.
- Provide follow up communication to customers about case progress offering realistic timelines and empathetic explanations that reduce uncertainty and support a positive overall service experience.
- Contribute to continuous improvement activities by identifying recurring customer issues summarizing patterns in Excel reports and recommending practical changes that simplify processes for members and internal stakeholders.
- Adhere to defined customer service standards and regulatory guidelines relevant to health care appeals and grievances helping safeguard data privacy and ethical handling of sensitive member information.
- Support knowledge sharing across the customer service team by documenting best practices and frequently asked questions in structured formats enabling quicker onboarding and more consistent responses.
- Participate in virtual training and coaching sessions to strengthen skills in MS Excel communication and case management ensuring ongoing growth and readiness to handle evolving customer needs.
- Assist in generating simple daily and weekly Excel based summaries of customer service performance helping management understand service levels and identify areas where process refinement can benefit members and society.
关于高知特 (Cognizant)
高知特(Cognizant)（纳斯达克代码：CTSH）作为一家AI Builder和相关技术服务提供商，致力于通过打造全栈AI解决方案，帮助企业将人工智能投资转化为实际价值。公司凭借深厚的行业经验、流程优化和工程技术专长，将企业独特的业务场景融入科技系统，赋能组织释放人才潜能，推动切实成果，并帮助全球企业在瞬息万变的环境中保持领先。如需了解更多详情，敬请访问 cognizant.ai 或关注@cognizant。
补充雇佣信息
薪酬信息截至本职位发布之日为准。Cognizant 保留在适用法律允许的范围内随时修改该信息的权利。
申请人可能需要通过现场面试或视频会议的方式参加面试。此外，候选人在每次面试时可能需要出示其当前所在州或政府签发的有效身份证件。
Cognizant 是一家提供平等就业机会的雇主。在招聘过程中，您的申请和候选资格不会因种族、肤色、性别、宗教、信仰、性取向、性别认同、国籍、残疾、遗传信息、怀孕、退伍军人身份或任何其他受联邦、州或地方法律保护的特征而受到影响。
