Eligibility Representative

Location: Bengaluru, India
Function: Healthcare Operations – Eligibility & Enrollment
Employment Type: Full‑Time
Shift: US / EMEA shifts (rotational as required)

Role Summary

The International Health Eligibility Representative is responsible for accurate eligibility verification, enrollment, maintenance, and updates for global health insurance members. The role ensures policy compliance, data accuracy, and SLA adherence, supporting seamless claims processing and member experience across international health plans.

Key Responsibilities

Eligibility Verification & Maintenance

• Perform eligibility verification for international health insurance members
• Process new enrollments, terminations, reinstatements, and plan changes
• Validate member demographics, coverage dates, benefit plans, and dependents
• Ensure accuracy of eligibility data to enable correct claims adjudication

Enrollment & Group Setup Support

• Support group setup, renewals, and benefit configuration
• Update eligibility records based on policy amendments and client instructions
• Coordinate with upstream/downstream teams to resolve eligibility discrepancies

Compliance & Documentation

• Follow client‑specific SOPs, international healthcare regulations, and data privacy standards
• Maintain accurate system documentation and audit trails
• Support internal and external audits with complete and compliant records

Stakeholder Coordination

• Respond to eligibility inquiries from claims teams, providers, and internal stakeholders
• Resolve issues within defined turnaround times (TATs)
• Escalate complex eligibility cases to SMEs or Team Leads as required

Continuous Improvement

• Identify recurring eligibility errors and recommend corrective actions
• Participate in process transitions, training, and refresher sessions
• Stay current with policy updates, benefit changes, and system enhancements

Key Skills & Competencies

Technical Skills

• Strong understanding of international health insurance eligibility & enrollment
• Knowledge of:
  • Benefit plans and policy interpretation
  • Member lifecycle management
  • Group setup and coverage rules
• Experience with eligibility systems, enrollment platforms, or healthcare workflow tools

Behavioral & Professional Skills

• High attention to detail and data accuracy
• Strong analytical and problem‑solving skills
• Effective written and verbal communication
• Ability to manage volume while meeting quality and SLA targets

Education & Experience

• Graduate in any discipline (Healthcare / Life Sciences preferred)
• 2–4 years of experience in:
  • International Health Eligibility & Enrollment OR
  • Global Healthcare BPO operations
• Exposure to US / EMEA health insurance clients is an advantage

Performance Metrics

• Accuracy of eligibility records
• SLA / TAT adherence
• Error and rework rates
• Productivity and volume handling
• Audit and compliance scores

Career Progression

• Senior Eligibility Representative
• Eligibility SME / Trainer
• Eligibility Quality Analyst
• Team Lead – Eligibility Operations

Preferred Attributes

• Willingness to work in global shifts
• Experience in large‑scale healthcare operations
• Exposure to transitions, migrations, or new client onboarding

About The Cigna Group

Cigna Healthcare, a division of The Cigna Group, is an advocate for better health through every stage of life. We guide our customers through the health care system, empowering them with the information and insight they need to make the best choices for improving their health and vitality. Join us in driving growth and improving lives.