Aetna Complaint & Appeal Anly in Plano, Texas

Req ID: 56303BR


Support comprehensive coordination of Fast Track Appeals. Promotes/supports quality effectiveness of Medicare Appeals process.

Fundamental Components:

  • Responsible for initial review and triage of appeal tasks. (*) Identifies and refers outlier cases (e.g., Length of Stay) to clinical staff.

  • Utilizes ATV and other Aetna systems to build, research and enter member information, as needed.

  • Promotes communication, both internally and externally to enhance effectiveness of medical management services (e.g.,health care providers, and health care team members respectively)

  • Performs non-medical research pertinent to the establishment, maintenance and closure of open cases

  • Provides support services to team members by answering telephone calls, taking messages, researching information and assisting in solving problems.

  • Adheres to Compliance with Medicare Policies and Regulatory Standards. Maintains accurate and complete documentation of required information that meets risk management, regulatory, and accreditation requirements.

  • Protects the confidentiality of member information and adheres to company policies regarding confidentiality.

  • Research incoming appeals to identify if appropriate for unit based upon published business responsibilities. Identify correct resource and reroute inappropriate work items that do not meet appeal criteria.

  • Identify and research all components within member or provider/practitioner appeals for Medicare products and services.

  • Triage incomplete components of 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 appeals including final communication to member/provider for final resolution and closure.

  • Serve as a technical resource to colleagues on 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 up to assure appeal is handled within established timeframe to meet company and regulatory requirements.


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. 2-4 years experience as a medical assistant, office assistant


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


Technology/Leveraging Technology/FOUNDATION


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.