The Complaint Analyst is responsible for working member grievances (complaints) within required timeframes, from intake to resolution. The review process could require coordination with multiple internal departments at the health plan as well as medical providers or other delegated entities. The Complaint Analyst is responsible for managing the lifecycle of the case and communicating the final resolution to the member or authorized representative
- Acknowledge and respond to member complaints, orally or in writing
- Coordinate issue resolution among multiple departments within required timeframes
- Provide guidance/coaching to frontline staff on specific cases
- Identify and trend systemic problems and make suggestions to improve or reduce the possibility of a reoccurrence
- Ensure the resolution appropriately addresses all issues raised in the complaint
- Communicate issue resolution, orally or in writing
- Monitor timeliness and ensure compliance with case work
- Strong verbal/written communication skills required.
- Must have Medicaid Experience
- 1-3 years' experience in customer service & handling complaints
- Ability to deescalate difficult situations while displaying compassion and empathy
- Ensure each issues was reviewed appropriately prior to resolution
- Well organized with ability to manage, prioritize & meet deadlines of cases
- Experience with claims and benefits a plus
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 provider appeal policies.Strong analytical skills focusing on accuracy and attention to detail.Knowledge of clinical terminology, regulatory and accreditation requirements.Excellent verbal and written communication skills.Computer literacy in order to navigate through internal/external computer systems, including Excel and Microsoft Word.
High School diploma, G.E.D. 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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