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.
Sobre a Cognizant
Cognizant (NASDAQ: CTSH) é uma construtora de IA e fornecedora de serviços de tecnologia, criando a ponte entre o investimento em IA e o valor para as empresas por meio do desenvolvimento de soluções de IA completas para nossos clientes. Nossa profunda experiência em setores, processos e engenharia nos permite incorporar o contexto único de cada organização em sistemas tecnológicos que potencializam a capacidade humana, geram resultados tangíveis e mantêm empresas globais à frente em um mundo em rápida transformação. Saiba mais em cognizant.ai ou @cognizant.
A Cognizant é uma empregadora que investe em equidade. Sua candidatura não será pautada em raça, cor, gênero, sexualidade, credo, origem, deficiência, gravidez ou qualquer outra característica protegida pelas leis brasileiras.
Informações adicionais de emprego
Os candidatos podem ser obrigados a comparecer a entrevistas presenciais ou por videoconferência. Além disso, os candidatos podem ser obrigados a apresentar seu documento de identificação emitido pelo estado ou governo atual durante cada entrevista.
Embora nosso sistema permita a candidatura em todos os idiomas, o(s) idioma(s) e o(s) nível(is) de proficiência exigidos para o trabalho variam. No entanto, é necessário um nível básico de inglês para fins de comunicação em toda a empresa.
A Cognizant é uma empregadora que investe em equidade. Sua candidatura não será pautada em raça, cor, gênero, sexualidade, credo, origem, deficiência, gravidez ou qualquer outra característica protegida pelas leis brasileiras.
Se você tem uma deficiência que requer adaptações razoáveis para procurar uma vaga de emprego ou enviar uma candidatura, envie um e-mail para [email protected] com sua solicitação e informações de contato.
