As the Appeal and Grievance Coordinator, you will be responsible for intake, investigation and resolution of appeals, complaints and grievances scenarios for all products. You will ensure timely, customer-focused response to appeals, complaints and grievances, and identify trends and emerging issues and report and recommend solutions.
Requirements
- Research incoming electronic appeals, complaints and grievance to identify if appropriate for unit based upon published business responsibilities
- 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
- Triage incomplete components of appeals, complaints and grievance to appropriate subject matter expert within another business unit(s) for resolution response content to be included in final resolution response
- Responsible for coordination of all components of appeals, complaints and grievance including final communication to member/provider for final resolution and closure
- Serve as a technical resource to colleagues regarding appeals, complaints and grievance issues, and similar situations requiring a higher level of expertise
- Identifies trends and emerging issues and reports on and gives input on potential solutions
- 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 appeals, complaints and grievance 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
Benefits
- Affordable medical plan options
- 401(k) plan (including matching company contributions)
- Employee stock purchase plan
- Wellness screenings
- Tobacco cessation and weight management programs
- Confidential counseling and financial coaching
- Paid time off
- Flexible work schedules
- Family leave
- Dependent care resources
- Colleague assistance programs
- Tuition assistance
- Retiree medical access
