Aetna Complaint & Appeal Analyst in Amherst, New York

Req ID: 38054BR

This is an office based role in one of the following offices: Tampa, FL, Amherst, NY, or Plymouth, MN.

POSITION SUMMARY

Appeal analyst is responsible for managing to resolution complaint/appeal scenarios, which may contain multiple issues and, may require coordination of responses from multiple business units. Ensure timely, customer focused response to complaints/appeals. Identify trends and emerging issues and report and recommend solutions.

Fundamental Components include but are not limited to:

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

-Research Plan Sponsor claim fiduciary responsibility, assemble data used in making the denial determination, assemble, summarize and send to Plan Sponsor contact.

-Research Standard Plan Design or Certification of Coverage pertinent to the member to determine accuracy/appropriateness of benefit/administrative denial.

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

-Identifies trends and emerging issues and reports on and gives input on potential solutions.

-Serve as a technical resource to colleagues on claim research, SPD/COC interpretation, letter content, state or federal regulatory language, triaging of complaint/appeal issues, and similar situations requiring a higher level of expertise.

-Follow up to assure complaint/appeal is handled within established timeframe to meet company and regulatory requirements.

BACKGROUND/EXPERIENCE

1-2 years experience that includes Traditional claim platforms, products and benefits; special investigations;or audit experience.

Understanding of Stop Loss/Reinsurance

Third Party Administrator Experience a plus

Experience in research and analysis of claim processing a plus.

Experience in reading or researching benefit language in SPDs or COCs.

Knowledge of clinical terminology, regulatory and accreditation requirements.

Strong analytical skills focusing on accuracy and attention to detail.

Excellent verbal and written communication skills.

Ability to meet demands of a high paced environment with tight turnaround times.

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

EDUCATION

The minimum level of education desired for candidates in this position is a High School diploma, G.E.D. or equivalent experience.

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.

Job Function: Risk Management