Aetna MCA Member Appeal Coordinator in Phoenix, Arizona
Req ID: 48991BR
Responsible for managing the resolution of Medicare Part C Appeals, which may contain multiple appealable issues and potential grievances
which may require coordination of responses from multiple business units. Ensure timely, customer focused response to all member
appeals. Identify trends and emerging issues and report and recommend solutions.
Research incoming electronic member appeals to identify if appropriate for unit based upon published business responsibilities. Identify correct resource and reroute inappropriate work items that do not meet member appeal criteria. (*)
Research Plan Sponsor claim fiduciary responsibility, assemble data used in making the final determination for an appeal, assemble, summarize and send to the Plan's Medical Director. (*)
Research Standard Plan Design or Certification of Coverage pertinent to the member to determine accuracy/ appropriateness of benefit/administrative approval or denial. (*)
Research prior authorization data, claim processing logic to verify accuracy of a claim payment or member reimbursement request, member eligibility data, billing/payment status, prior to initiation of appeal process. (*)
Identify and research all components within member appeals for all products and services. (*)
Triage incomplete components of member appeal requests, that contain grievances, to the 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 member appeals including final communication to member/ provider for final resolution and closure. (*)
Serve as a technical resource to colleagues on prior authorization and/or claim research, letter content, state or federal regulatory language, triaging of appeal issues, and similar situations requiring a higher level of expertise. (*)
Identifies trends and emerging issues and reports on and gives input on potential solutions.
Follow CMS turnaround times to assure all member appeals are handled within established timeframe to meet company and regulatory requirements. (*)
Act as single point of contact for the all appeals on behalf of members, member representative's and/or providers, as assigned.
1-3 years experience with Medicare Benefits required
Experience in research and analysis of Medicare Part C appeals required.
Customer Service and provider relations experience
Data entry skills
Ability to research and resolve problems
The highest level of education desired for candidates in this position is a High School diploma, G.E.D. or equivalent experience.
Option for telework will be evaluated after a certain period of employment. Production and performance will be assessed prior to approval.
ADDITIONAL JOB INFORMATION
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