Aetna KS MCD Manager, Grievance and Appeal (51778BR) in Overland Park, Kansas

Req ID: 51778BR


The Grievances and Appeals Manager is responsible for coordinating the effective resolution of member or provider/practitioner appeals. The Grievance and Appeals manager is responsible for establishing and maintaining in collaboration with all segments and business units, consistent policies and procedures defining the administration and the resolution of complaints grievances and appeals from Aetna member and providers compliant with legislative, regulatory and accreditation requirements and maintaining this infrastructure to assure ease of use and consistent resolution responses are accessible to all operational resolution teams and business units and subject matter experts.

Fundamental Components:

Manages team's productivity and resources, communicates productivity expectations and balances workload to achieve customer satisfaction through prompt/accurate handling of customer concerns

Manages a team of clinical and or non-clinical personnel (clinical mgmt for clinical staff/MRT

Serves as a content model expert and mentor to team in regards to Aetna's policies and procedures, regulatory and accreditation requirements

Manages to performance measures and standards for quality service and cost effectiveness and coaches team/individuals to take appropriate action

Select staff using clearly defined requirements in terms of education, experience, technical and performance skills

Build strong functional teams through formal training, diverse assignments, coaching, mentoring and other developmental techniques

Assesses developmental needs and collaborates with others to identify and implement action plans that support the development of high performing teams and individuals

Ensures work of team meets federal and state requirements and quality measures, with respect to letter content and turnaround time for Appeals and Complaints handling

Ensures all Complaints and Appeals units are utilizing the National tracking tool to ensure reporting consistency and trend analysis

Identifies trends involving non-clinical & clinical issues and reports on and recommends solutions

Sedentary work involving significant periods of sitting, talking, hearing and keying. Work requires visual acuity to perform close inspection of written and computer generated documents as well as a PC monitor. Working environment includes typical office conditions


Prefer 1 year clinical experience - required for managing clinical staff (MRT). Experience working with managed and non-managed health care benefits.

1-3 years supervisory experience. Experience in research and analysis of claim processing a plus.

Education and Certification Requirements:

Bachelor's degree or equivalent work experience in Healthcare, Project Management, Audit, Systems Design.

Excellent verbal and written communication skills

Knowledge of clinical terminology, regulatory and accreditation requirements

Knowledge and experience with Complaints and Appeals and Regulatory Requirements

Sound judgment

Strong analytical skills focusing on accuracy and attention to detail

Computer literacy in order to navigate through internal/external computer systems, including Excel and Microsoft Word


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


General Business/Maximizing Work Practices/ADVANCED

Leadership/Collaborating for Results/ADVANCED

Benefits Management/Interacting with Medical Professionals/ADVANCED


General Business/Communicating for Impact/ADVANCED

Finance/Delivering Profit and Performance/ADVANCED

Leadership/Creating Accountability/ADVANCED


Are you ready to join a company that is changing the face of health care across the nation? Aetna Better Health of Kansas is looking for people like you who value excellence, integrity, caring and innovation. As an employee, you ll join a team dedicated to improving the lives of KanCare members. Our vision incorporates community-based health care that works. We value diversity. Align your career goals with Aetna Better Health of Kansas, and we will support you all the way. 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