Appeal and Grievance Coordinator

• Intake, investigation and resolution of appeals, complaints and grievances scenarios for all products
• Research incoming electronic appeals, complaints and grievance to identify if appropriate for unit
• Research Standard Plan Design or Certification of Coverage relevant to the member
• Research claim processing logic to verify accuracy of claim payment
• Identify and research all components within member or provider/practitioner appeals, complaints and grievance
• Triage incomplete components to appropriate subject matter expert
• Coordinate all components of appeals, complaints and grievance including final communication
• Serve as a technical resource to colleagues regarding appeals, complaints and grievance issues
• Identify trends and emerging issues and report on potential solutions

• Experience in reading or researching benefit language
• 1-2 years experience in claim platforms, products, and benefits
• patient management
• product or contract drafting
• compliance and regulatory analysis
• special investigations
• provider relations
• customer service or audit experience
• Ability to meet demands of a high paced environment with tight turnaround times
• Ability to make appropriate decisions based upon Aetna's current policies/guidelines
• Collaborative working relationships
• Thorough knowledge of member and/or provider appeals, complaints and grievance policies
• Strong analytical skills focusing on accuracy and attention to detail
• Knowledge of clinical terminology, regulatory and accreditation requirements
• Excellent verbal and written communication skills
• Computer literacy in order to navigate through internal/external computer systems, including Excel and Microsoft Word

Experience in research and analysis of claim processing

• Affordable medical plan options
• 401(k) plan with matching company contributions
• Employee stock purchase plan
• Wellness screenings
• Tobacco cessation programs
• Weight management programs
• Confidential counseling
• Financial coaching
• Paid time off
• Flexible work schedules
• Family leave
• Dependent care resources
• Colleague assistance programs
• Tuition assistance
• Retiree medical access