Remote Cigna Claims Representative Jobs in Silver Spring, MD

Join our team as a Provider Network Operations Advisor, playing a key role in creating and maintaining provider networks that deliver quality, affordability, and access to care. This role shapes provider network strategy across a matrixed group of partners, using data to driveinitiatives that support Cigna Enterprise goals and directly impact our clients and customers.

Key Responsibilities

Provider Data Resolution

• Support the management and implementation of provider, hospital, and ancillary networks by researching and resolving provider data issues, including demographic, claims, and system loading errors.
• Troubleshoot issues escalated by Market Network Advisors using Cigna systems such as HCPM, Cognos, and the Developer Database.
• Respond to questions from the Contracting team and matrix partners related to provider locations, policies, and data accuracy.
• Perform rate and fee schedule audits upon request.
• Support accurate loading of provider contracts and reimbursement methodologies.

Market Guidebooks

• Create, manage, and maintain Market Guidebooks, including rate updates, provider inclusion/exclusion, and audit documentation.
• Advise Market leadership and the National Alternative Access Network Manager on market-specific network dynamics.
• Participate in quarterly reviews, identify corrections, and assist with provider terminations, additions, and updates.

Alternative Access Network (AAN)

• Serve as the market subject matter expert for Alternative Access Networks, including inclusion/exclusion criteria and anchor providers.
• Develop and maintain the AAN field guide for Contracting teams.
• Coordinate, edit, and approve AAN communications, such as provider notices and Sales materials.
• Conduct provider research and approve mailing lists for new or expanded product offerings.
• Perform ongoing network maintenance, answer questions, and resolve issues.
• Partner with the Network Manager on Split TIN handling and loading for IFP.

Affordability

• Facilitate monthly affordability calls and agendas.
• Monitor opportunity detection tools and support total medical cost savings through provider research, claims analysis, action planning, and outcome monitoring.
• Partner with Market Medical Directors and Data Analytics on savings opportunities.
• Perform medical benchmarking and network modeling using HPN tools.

Compliance - Network Adequacy & State Filings

• Partner with matrix teams to ensure accurate provider data for filings, including hospital listings and state-specific requirements for the Mid-Atlantic market.
• Support recruitment efforts to address network adequacy gaps by validating provider locations, specialties, and viability.

HSCRC - State of Maryland

• Represent the market on monthly state-facilitated calls.
• Provide regulatory updates to Contracting leadership and the Market Medical Director.
• Participate in AHEAD learning activities and support related initiatives.

Regulatory Compliance - Mid-Atlantic

• Support subject matter expertise related to the No Surprises Act, CMS guidance, and federal and state regulations.
• Partner with business owners to ensure workflows and policies are implemented in a timely manner.
• Identify operational gaps and recommend process improvements.

Qualifications

• Bachelor's degree or equivalent experience required.
• 5+ years of experience in provider network management or healthcare insurance.
• Project management experience preferred.
• Strong analytical, problem-solving, and critical-thinking skills.
• Excellent communication, stakeholder management, and organizational skills.
• Healthcare compliance and regulatory experience preferred.
• Knowledge of CMS regulations, NSA, and reimbursement structures preferred.
• Ability to work independently and manage multiple priorities.
• Proficiency in Microsoft Office; Cigna systems experience preferred.
• Local market knowledge preferred.