Aetna Complaint and Appeal Manager in Linthicum, Maryland

Req ID: 53290BR

POSITION SUMMARY

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.

This is a working manager position and you will be expected to work cases.

Fundamental Components:

Manage the Plan's appeal and grievance function so that it meets regulatory requirements.

Develop a culture of providing superior service to enhance member & provider experience with the Plan's grievance and appeal handling.

Develop staff.

Represent the Plan at State Fair Hearings, internal and external audits.

Build strong, collaborative relationships with local and national team members and partners.

BACKGROUND/EXPERIENCE desired:

Required:

5+ years of experience processing complaint, grievance and appeal cases in a health plan or managed care organization

3+ years of experience in coding and claims process

3+ years of experience working directly with state and federal regulators and accreditation entities (e.g. Maryland Department of Health; CMS; NCQA; etc.)

2+ years of performing file audits on complaint, grievance and appeal cases

3+ years of supervisory experience

Preferred:

3 - 5 years clinical experience (e.g. RN)

Medical coding and billing certification

EDUCATION

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

FUNCTIONAL EXPERIENCES

Functional - Claims/Claim processing - Medical or Hospital- HMO/1-3 Years

Functional - Management/Management - Operations/4-6 Years

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

Functional - Customer Service/FE Complaints, grievances & appeals/4-6 Years

TECHNOLOGY EXPERIENCES

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

Technical - Desktop Tools/Microsoft Word/7-10 Years/

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

Technical - Desktop Tools/Microsoft PowerPoint/4-6 Years/

REQUIRED SKILLS

Leadership/Driving Change/ADVANCED

Leadership/Engaging and Developing People/ADVANCED

Finance/Delivering Profit and Performance/ADVANCED

DESIRED SKILLS

Leadership/Driving a Culture of Compliance/ADVANCED

Benefits Management/Interacting with Medical Professionals/ADVANCED

General Business/Communicating for Impact/ADVANCED

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.

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.