Aetna Complaint & Appeal Anly in Louisville, Kentucky

Req ID: 43908BR

Candidate will be working full time from the Louisville, KY office; Potential for WAH after a certain time of employment, reviewed on a case by case basis.


Coordinates effective resolution of member and or provider appeals and grievances.

Fundamental Components:

Research incoming electronic complaints/appeals to identify if appropriate for unit based upon published business responsibilities. Identify correct resource and reroute inappropriate work items that do not meet complaint/appeal criteria. (*)

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 complaints/appeals for all products and services. (*)

Triage incomplete components of complaints/appeals 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 complaints/appeals including final communication to member/provider for final resolution and closure. (*)

Identifies trends and emerging issues and reports on and gives input on potential solutions.

Follow up to assure complaint/appeal is handled within established timeframe to meet company and regulatory requirements. (*)


Medical claims experience 1-3 years is REQUIRED.

1-2 years experience that includes both HMO and Traditional claim platforms, products, and benefits; patient management; product or contract drafting; compliance and regulatory analysis; special investigations; provider relations; customer service or audit experience.

Experience in research and analysis of claim processing a plus.


The highest level of education desired for candidates in this position is a Associate's degree or equivalent experience.


Functional - Claims/Claim processing - Medical or Hospital- HMO/1-3 Years

Functional - Administration / Operations/Data Entry/1-3 Years

Functional - Administration / Operations/Telephone / Receptionist/1-3 Years


Technical - Desktop Tools/Microsoft Outlook/1-3 Years/

Technical - Desktop Tools/Microsoft PowerPoint/1-3 Years/

Technical - Desktop Tools/Adobe Acrobat Suite v5/1-3 Years/


Benefits Management/Interacting with Medical Professionals/ADVANCED


Service/Creating a Differentiated Service Experience/ADVANCED

Technology/Leveraging Technology/FOUNDATION

Telework Specifications:

Option for telework will be evaluated after a certain period of employment


Aetna is about more than just doing a job. This is our opportunity to re-shape healthcare for America and across the globe. We are developing solutions to improve the quality and affordability of healthcare. What we do will benefit generations to come.

We care about each other, our customers and our communities. We are inspired to make a difference, and we are committed to integrity and excellence.

Together we will empower people to live healthier lives.

Aetna is an equal opportunity & affirmative action employer. All qualified applicants will receive consideration for employment regardless of personal characteristics or status. We take affirmative action to recruit, select and develop women, people of color, veterans and individuals with disabilities.

We are a company built on excellence. We have a culture that values growth, achievement and diversity and a workplace where your voice can be heard.

Benefit eligibility may vary by position. Click here to review the benefits associated with this position.

Aetna takes our candidate's data privacy seriously. At no time will any Aetna recruiter or employee request any financial or personal information (Social Security Number, Credit card information for direct deposit, etc.) from you via e-mail. Any requests for information will be discussed prior and will be conducted through a secure website provided by the recruiter. Should you be asked for such information, please notify us immediately.

Job Function: Risk Management