Aetna Complaint & Appeal Analyst in Pittsburgh, Pennsylvania
Req ID: 44546BR
Responsible for managing to resolution complaint/appeal 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
complaints/appeals. Identify trends and emerging issues and report and recommend solutions.
Process Medicare Member Appeals within the timeframe outlined by Medicare. Ability to adhere to the strict resolution timeframes established by the regulatory agencies. Collaboration with clinical constituents during the research phase of cases in inventory. Ability to handle a high volume of work in a fast pace environment. Maintain department production standards. Ability to understand and adhere to legislative and regulatory standards that impact the company STARS metrics.
1+ 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.
Experience in reading or researching benefit language in SPDs or
The minimum level of education desired for candidates in this position is a Bachelor's degree or equivalent experience.
Functional - Products-Medical/Individual Medicare Advantage Plan/4+ Years
Functional - Medical Management/Medical Management - Clinical coverage and policies/4+ Years
Functional - Medical Management/Medical Management - Complaints, Grievance & Appeals/4+ Years
Functional - Medical Management/Medical Management - Home health care/4+ Years
Functional - Medical Management/Medical Management - Legislative and regulatory compliance/4+ Years
Technical - Computer Operations/System and Console Operations/4+ Years/End User
Technical - Remote Access/Broadband VPN/4+ Years/End User
Technical - Hardware/PCs/4+ Years/End User
Technical - Hardware/Mainframe/4+ Years/End User
Leadership/Collaborating for Results/ADVANCED
Service/Providing Solutions to Constituent Needs/FOUNDATION
General Business/Communicating for Impact/ADVANCED
General Business/Maximizing Work Practices/ADVANCED
Leadership/Driving a Culture of Compliance/ADVANCED
ADDITIONAL JOB INFORMATION
The team is a team collaborates on a regular basis. This team has many with very high skill set and they are very enthused with supporting any addition to staff. This team has a very low turn over rate. The team is very unique and perform high level review of Member appeals. This is a very rewarding position as it allows all to help our Medicare membership. The team is very member focused.
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