Aetna Appeals Nurse Associate (Virginia Medicaid) in Richmond, Virginia

Req ID: 51541BR

Position Summary:

Responsible for the review and resolution of clinical complaints and appeals. Interprets data obtained from clinical records to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and provider issues. Independently coordinates the clinical resolution with internal/external clinician support as required. Requires LPN/LVN with unrestricted active VA state license.

Job Responsibilities:

  • Assists with reviewing complaint/appeal requests of all clinical determinations/clinical policies.

  • Considers all previous information as well as any additional records/data presented to prepare a recommendation.

  • Assists with data gathering that requires navigation through multiple system applications.

  • Contacts the provider of record, vendors, or internal Aetna departments to obtain additional information

  • Accurately applies review requirements to assure case is reviewed by a practitioner with clinical expertise for the appeal issue at hand (e.g. Specialty Match Review (SMR), RN, MD, etc.).

  • Commands a comprehensive knowledge of complex delegation arrangements, coding logic, contracts (member and provider), clinical criteria, benefit plan structure, regulatory requirements, and ERO eligibility which are required to support the appeals determinations.

  • Pro-actively and consistently applies the regulatory and accreditation standards to assure that appeals and ERO requests are processed within requirements.

  • Assists with condensing information from multiple sources (i.e., contract, coding, regulatory, etc.) into a clear and precise clinical picture for presentation to an appropriate clinician for determination.

  • Seeks guidance from other healthcare professionals in the coordination and administration of the appeals process

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

  • Responsible for coordination of all components of complaints/appeals including final communication to member/provider of final resolution and closure.

  • Ensure that complaints/appeals are handled within established timeframe to meet company and regulatory requirements.

  • Identify trends and emerging issues and reports on and gives input on potential solutions.

  • 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.

  • Research claims processing logic to verify accuracy of claim payment, member eligibility data, billing/payment status, prior to initiation of appeal process.

    Background/Experience Desired:

  • 2-4 years of clinical experience required, managed care experience preferred

  • Proficiency with computer, MS Office Suite and keyboard navigation skills are required

  • Effective communication skills, verbal, written and presentation

  • Ability to multitask, prioritize and effectively adapt to a fast paced changing environment

  • Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer

  • Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor

  • Typical office working environment with productivity and quality expectations


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

    Licenses and Certifications:

    Nursing/Licensed Practical Nurse (LPN) is desired

    Nursing/Licensed Vocational Nurse (LVN) is desired

    Functional Experiences:

    Functional - Clinical / Medical/Clinical claim review & coding/1-3 Years

    Functional - Medical Management/Medical Management - Direct patient care/1-3 Years

    Functional - Nursing/Clinical claim review and coding/1-3 Years

    Functional - Administration / Operations/File Maintenance/1-3 Years

    Functional - Medical Management/Medical Management - Complaints, Grievance & Appeals/1-3 Years

    Technology Experiences:

    Technical - Desktop Tools/Microsoft Word/4-6 Years/End User

    Technical - Desktop Tools/TE Microsoft Excel/4-6 Years/End User

    Technical - Desktop Tools/Microsoft Outlook/4-6 Years/End User

    Technical - Desktop Tools/Microsoft SharePoint/1-3 Years/End User

    Required Skills:

    Benefits Management/Interacting with Medical Professionals/ADVANCED

    Benefits Management/Understanding Clinical Impacts/FOUNDATION

    General Business/Applying Reasoned Judgment/FOUNDATION

    Desired Skills:

    Leadership/Collaborating for Results/ADVANCED

    Technology/Leveraging Technology/FOUNDATION

    Service/Providing Solutions to Constituent Needs/FOUNDATION

    Additional Job Information:

    Are you ready to join a company that is changing the face of health care across the nation? Aetna Better Health of Virginia 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 Virginia Medicaid members. Our vision incorporates community-based health care that works. We value diversity. Align your career goals with Aetna Better Health of Virginia, 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. 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.

    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.

    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: Health Care