Aetna Grievance & Appeals Analyst in San Diego, California
Req ID: 50155BR
The Grievance and Appeals Analyst is responsible for managing to resolution complaint/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 complaints/appeals. Identify trends and emerging issues and report and recommend solutions
Research incoming electronic 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. Identify and research all components within member or provider/practitioner complaints/appeals for all products and services. () -Triage incomplete components of complaints/appeals to appropriate subject matter expert within another business unit(s) for resolution response content to be included in final resolution response. () -Responsible for coordination of all components of complaints/appeals including final communication to member/provider for final resolution and closure. () -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. () -Identifies trends and emerging issues and reports on and gives input on potential solutions. -Follow up to assure complaint/appeal is handled within established timeframe to meet company and regulatory requirements. () -Act as single point of contact for the Executive complaints and appeals and Department of Insurance, Department of Health or Attorney General complaints or appeals on behalf of members or providers, as assigned.
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; provider relations; customer service or audit experience. Experience in research and analysis of claim processing a plus. Experience reading or researching benefit language in SPDs/COCs. Advanced technical skills with MS Office Suite. Excellent communication and organizational skills.
The highest level of education desired for candidates in this position is a High School diploma, G.E.D. or equivalent experience.
Functional - Medical Management/Medical Management - Complaints, Grievance & Appeals/1-3 Years
Functional - Medical Management/Medical Management - Legislative and regulatory compliance/1-3 Years
Functional - Customer Service/FE Complaints, grievances & appeals/1-3 Years
Functional - Claims/Claim processing - Medical or Hospital- HMO/1-3 Years
Functional - Administration / Operations/FE Correspondence / Reports/1-3 Years
Technical - Desktop Tools/Microsoft Word/1-3 Years/End User
Technical - Desktop Tools/TE Microsoft Excel/1-3 Years/End User
Technical - Desktop Tools/Microsoft Outlook/4-6 Years/End User
Technical - Desktop Tools/Microsoft SharePoint/1-3 Years/End User
Benefits Management/Interacting with Medical Professionals/ADVANCED
Service/Creating a Differentiated Service Experience/ADVANCED
General Business/Maximizing Work Practices/ADVANCED
General Business/Communicating for Impact/ADVANCED
General Business/Demonstrating Business and Industry Acumen/FOUNDATION
ADDITIONAL JOB INFORMATION
Are you ready to join a company that is changing the face of health care across the nation? Aetna Better Health of California is looking for people like you who value excellence, integrity, caring and innovation. As an employee, youll join a team dedicated to improving the lives of the most vulnerable in our population. Our vision incorporates community-based health care that works. We value diversity. Align your career goals with Aetna Better Health of California, and we will support you all the way.
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 candidate'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