Monday , May 20 2024

Aetna Employment – Appeal Analyst

Website Aetna

Job Description:

Responsible for Oversight of that that investigates and resolution of appeals 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 appeals. Identify trends and emerging issues and report and recommend solutions. Independently coaches others on complaints and appeals ensuring compliance with Federal and/or State regulations. Manage control and trend inventory, independently investigate, change or revise policy to resolve the most escalated cases coming from broad, internal and external constituents for all products and issues.

Job Responsibilities:

  • Successfully works across functions, segments, and teams to create, populate, and trend reports to find resolution to escalated cases.
  • Identify potential risks and cost implications to avoid incorrect or inaccurate responses and/or decisions which may result in additional rework, confusion to the constituents, or legal ramifications.
  • Manages inventories to ensure state guidelines are met.
  • Educates analysts and business units of identified issues and potential risk.-Initiates and encourages open and frequent communication between constituents.
  • Serves as a content model expert and mentor to team regarding Aetna’s policies and procedures, regulatory and accreditation requirements.
  • Ensures work of team meets federal and state requirements and quality measures, with respect to letter content and turn-around time for appeals, complaints and grievances handling.
  • Identifies trends and emerging issues and reports on and gives input on potential solutions.
  • Independently researches and translates policy and procedures into intelligent and logically written responses for ERT/SMRT/DOI/BBB and escalated cases.

Job Requirements:

  • Associates degree or equivalent experience
  • Preferred 3+ years of experience in a Customer Service
  • At least 3 years of experience that includes but is not limited to 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 reading or researching benefit language.
  • Excellent verbal and written communication skills.
  • Ability to work an Alternate schedule.
  • Knowledge of Medicare and Medicaid regulations

Job Details:

Company: Aetna

Vacancy Type: Full Time

Job Location: Pittsburgh, PA, US

Application Deadline: N/A

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