Aetna Complaint & Appeals Consultant - Healthcare in New Albany, Ohio

Req ID: 55957BR


Subject matter expert (SME) and 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.

Independently manage all department of insurance and executive complaints, and solely responsible for handling and responding to all media relations.

Responsible for compliance with policies of all applicable Federal and/or State government agencies, including but not limited to Center for Medicaid and Medicare (CMS), Department of Public Welfare, Department of Health, and Department of Insurance.

Fundamental Components:

*Responsibilities will have national scope and require familiarity with national regulations and legislation.

*Independently researches, translates organizational policy into intelligent and logically written and/or verbal responses to media relations, regulators, government agencies, or cases that come through the executive complaint line, for all products and issues pertaining to members or providers.

*Demonstrates Best in Class letter writing skills. All letters are drafted individually based on current findings, regulations and legislation

*Manages inventories to ensure state guidelines are met. Responsible for making sure workflows are kept up to date with most current regulations and legislation.

*Creates and communicates appeal policies, procedures, and outcomes with all levels of the organization.

*Educates analysts and business units of identified issues and potential risk.

Initiates and encourages open and frequent communication, between constituents, to dissect policies, trends, and workflows, in turn identifying areas in need of improvement, throughout various departments.

*Successfully works across functions, segments, and teams to create, populate, and trend reports to find resolution to escalated cases.

*Independently takes complete ownership of their responses as their findings may result in mitigating negative publicity or stopping the trigger of an external audit or fine.

*Considers potential risks and cost implications as an incorrect or inaccurate response and/or decision may result in additional rework, confusion to the constituents, or legal ramifications.

*Must have excellent knowledge on how to effectively use all tools associated with appeals and claim processing and all claim processing screens).

*Expert knowledge of the healthcare industry both internally and externally across other insurance companies.

*Exhibits the following Complaint & Appeals Consultant Behaviors

*Surpasses the behaviors outlined in the Sr. Complaint & Appeal Analyst Competencies.


*3-5 years experience as a Complaint and Appeal Analyst, or Consultant

*5 years of superior claim research knowledge or claim processing experience.

*Experience as an assistant Team Lead, Team Lead or Project Manager is a plus

*Knowledge of ICD-9 and CPT codes desired.


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


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

  • Desktop Tools/Microsoft Word/1-3 Years/


    Leadership/Driving a Culture of Compliance/ADVANCED

    Leadership/Creating Accountability/MASTERY


    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 candidates'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

Aetna is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected Veterans status.