Aetna Mgr, Complaint &Appl Prog in Moon township, Pennsylvania
Req ID: 38241BR
Establish and Maintain in collaboration with all segments and business units, consistent policies and procedures defining the administration and resolution of complaints grievances and appeals from Aetna member and providers compliant with legislative, regulatory and accreditation requirements. Maintain 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.
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 turn around 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. (*)
Holds individuals/team accountable for results; recognize/reward as appropriate. (*)
Lead change efforts while managing transitions within a team. (*)
Identifies trends involving non-clinical & clinical issues and reports on and recommends solutions. (*)
Additional duties as assigned, (e.g., Supervisors with less than 15 direct reports will also handle resolution work the % of the time they are not managing their staff).
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.
3-5 years 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.
The highest level of education desired for candidates in this position is a Bachelor's degree or equivalent experience.
ADDITIONAL JOB INFORMATION
Bachelor's degree or 5 years equivalent work experience in Healthcare, Project Management, Audit, Systems Design
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