Aetna Complaint & Appeal Anly in Harrisburg, Pennsylvania

Req ID: 54634BR


Responsible for managing to resolution Pre Service appeal scenarios for all products, which may contain multiple issues and, may require coordination of responses from multiple business units. Ensure timely, customer focused response to appeal requests. Identify trends and emerging issues and report and recommend solutions.

Fundamental Components:

In the position, the following functions will be performed:

  • Review of contract materials to determine if coverage criteria met.

  • Interpret Medicare Regulations - Draft letters to members in a clear and concise manner.

  • Update internal system, documenting the activity of case file review with clarity and accuracy.

  • Maintain accountability for resolving each case within established timeframes.

  • Recognize trends and provide solutions.


4-6 years Medicare experience is a plus. - Candidate should have claims knowledge to include the ability to navigate through the claims systems. - Must resolve each and every case in accord with the regulatory time frames.


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


Functional - Medical Management/Medical Management - Legislative and regulatory compliance/1-3 Years

Functional - Medical Management/Medical Management - Network Management/1-3 Years

Functional - Medical Management/Medical Management - Dental/1-3 Years

Functional - Medical Management/Medical Management - Complaints, Grievance & Appeals/4-6 Years

Functional - Claims/Claim processing - Medical - Medicare/4-6 Years


Technical - Mainframe Tools and Software/TE Rumba/1-3 Years/End User

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

Technical - Aetna Applications/Automated Claim Adjudication System/4-6 Years/End User

Technical - Aetna Applications/Aetna Document Search/4-6 Years/End User


Leadership/Collaborating for Results/ADVANCED

Leadership/Driving a Culture of Compliance/ADVANCED

Service/Providing Solutions to Constituent Needs/FOUNDATION


Benefits Management/Interacting with Medical Professionals/ADVANCED

General Business/Communicating for Impact/ADVANCED

General Business/Maximizing Work Practices/ADVANCED


Must have the ability to exemplify Aetna values in daily work, promote collaborative relationships with others and foster a sense of teamwork with internal/external constituents which includes regular interaction with medical providers, peers, Medicare members, regulatory agencies and the management team. Must be able to multi-task in a fast paced environment. Must remain flexible with the ability to adapt to change in the work environment and perform assigned tasks with accuracy. Must be able to adjust to regulatory, departmental and workflow changes. Must have the skill set to communicate and draft correspondence to internal/external constituents in a clear and concise manner. Must have the ability to adhere to strict regulatory timeframes and meet established metrics. Must maintain focus on producing high quality work and resolving cases in a timely fashion. Organization skills are essential and a tool used to maintain compliance with individual inventory assignment. Medicare knowledge is a plus.

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.