Aetna Medicare Complaint & Appeal Analyst (Expedited Appeals Team) in Pittsburgh, Pennsylvania

Req ID: 38059BR

Please note that this position is an in-office role, and is open to candidates within a commutable distance to either our Moon PA (preferred), Blue Bell PA, or Pittsburgh PA office locations.


As a Medicare Complaint & Appeal Analyst, you will support the Medicare Appeal Expedited Appeal team. The cases processed are time sensitive based on guidance outlined in Medicare Regulations.

Fundamental Components of the Medicare Complaint & Appeal Analyst position include, but are not limited to:

Knowledge of the Medicare Appeal Process. Ability to properly categorize an appeal versus a Grievance or Part D Appeal. Adhere to the departmental Work Instructions and Standard Operating Procedures. Apply and adhere to CMS timeliness standards to all cases reviewed. Have the ability to properly identify member from non-contracted provider cases. Great organizational skills required due to the caseload volume. System knowledge with the ability to determine the contractual status of the providers submitting the appeal. Elevating trends that may pose a negative impact to the business, our members or internal/external constituents. Being a part of the solution to help the team remain successful. Meet the departmental production and quality metrics. Ability to handle a large case load and provide the proper oversight of cases assigned. Great attention to details. Elevate problematic issues within a timely manner to management team. Be a part of the solution to trends that could impact the member. Maintain a focus on keeping the member first in all we do. Timely outreach to our customers throughout the life of the appeal. Remain a team player. Must have the ability to accurately monitor a case load of cases which require resolution in a short timeframe, in accord with Medicare Guidelines. Ability to work an alternative work schedule.BACKGROUND/EXPERIENCE desired:

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; customer service or audit experience required. Experience in research and analysis of claim processing a plus. Experience in reading or researching benefit language in SPDs or COCs.


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


Technical - Aetna Applications/Medicare Evidence of Contract/1-3 Years/End User

Technical - Aetna Applications/Aetna Total clinical View/1-3 Years/End User

Technical - Aetna Applications/Enterprise Provider Database System/1-3 Years/End User

Technical - Aetna Applications/Mainframe Provider Database/1-3 Years/End User


General Business/Communicating for Impact/ADVANCED

Leadership/Driving a Culture of Compliance/ADVANCED

Service/Providing Solutions to Constituent Needs/FOUNDATION


General Business/Maximizing Work Practices/ADVANCED

Service/Handling Service Challenges/ADVANCED

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.

Job Function: Risk Management