Responsible for intake, investigation and resolution of appeals, complaints and grievances scenarios for all products, which may contain multiple issues and, may require coordination of responses from multiple business units. Ensure timely, customer focused response to appeals, complaints and grievance. Identify trends and emerging issues and report and recommend solutions. Independently coaches others on complaints and appeals ensuring compliance with Federal and/or State regulations. Manage control and trend inventory, independently investigate, change or revise policy to resolve the most escalated cases coming from broad, internal and external constituents for all products and issues. Responsible for serving as the main point of contact for plan leadership, compliance and State regulators as required. Will handle ERT/SMRT/DOI/BBB and escalated cases.
-Serves as a content model expert and mentor to team regarding Aetna's policies and procedures, regulatory and accreditation requirements.
-Ensures work of team meets federal and state requirements and quality measures, with respect to letter content and turn-around time for appeals, complaints and grievances handling.
-Identifies trends and emerging issues and reports on and gives input on potential solutions.
-Independently researches and translates policy and procedures into intelligent and logically written responses for ERT/SMRT/DOI/BBB and escalated cases.
-Manages inventories to ensure state guidelines are met.
-Educates analysts and business units of identified issues and potential risk.
-Initiates and encourages open and frequent communication between constituents.
-Successfully works across functions, segments, and teams to create, populate, and trend reports to find resolution to escalated cases.
-Identify potential risks and cost implications to avoid incorrect or inaccurate responses and/or decisions which may result in additional rework, confusion to the constituents, or legal ramifications.
-Additional duties as assigned which will include a carrying a modified case load including but not limited to:
-Research incoming electronic appeals, complaints and grievance to identify if appropriate for unit based upon published business responsibilities. Identify correct resource and reroute inappropriate work items that do not meet appeals, complaints and grievance criteria.
-Research Standard Plan Design or Certification of Coverage relevant to the member to determine accuracy/appropriateness of benefit/administrative denial.
-Research claim processing logic to verify accuracy of claim payment, member eligibility data, billing/payment status, prior to initiation of appeal process.
-Identify and research all components within member or provider/practitioner appeals, complaints and grievance for all products and services.
-Experience in reading or researching benefit language.
-Excellent verbal and written communication skills.
-Preferred 3-5 years of experience in a Complaint and Appeal Analyst role
-At least 5 years of experience that includes but is not limited too claim platforms, products, and benefits; patient management; product or contract drafting; compliance and regulatory analysis; special investigations; provider relations; customer service or audit experience.
-Strong knowledge of the external review process related to federal and state regulations
-Knowledge of ICD-9 and CPT codes desired
-Experience as an assistant Team Lead, Team Lead or Project Manager preferred
-2 - 5 years clinical experience preferred
Additional Job Information
-Ability to meet demands of a high paced environment with tight turnaround times.
-Ability to make appropriate decisions based upon Aetna's current policies/guidelines.
-Collaborative working relationships.
-Thorough knowledge of member and/or provider appeal, complaint and grievance policies.
-Strong analytical skills focusing on accuracy and attention to detail.
-Ability to work across Aetna functions, segments and markets to accomplish business goals.
-Ability to multi-task to accomplish workload efficiently.
-Ability to revise priorities as appropriate to respond to change.
-Excellent verbal and written communication skills.
-Strong analytical skills
-Autonomously makes decisions based upon current policies/guidelines-Acts decisively to ensure business continuity and with awareness of all possible implications and impact
Bachelor's degree or equivalent experience
Percent of Travel Required
0 - 10%
At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.
We are committed to maintaining a diverse and inclusive workplace. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.
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