Sr Complaint Appeal Anly
Posted on: 22 Jan 2021
Lansing, MI
Job Description
Job Description
- Research and resolves escalations member/provider (complaints/concerns) through extensive research using various sources and applications.
- Ability to identify trends and process improvement opportunities and provide viable solutions.
- Research standard plan design, certification of coverage and potential contractual deviations to determine accuracy and appropriateness of a benefit/administrative denial.
- Ability to research claim processing logic/guidelines and various other systems to verify accuracy of claim adjudication, member eligibility and billing/payment status.
- Coordinates efforts internally and across departments to successfully resolve claim concerns. Facilitate meetings with all levels across the organization.
- Ability to create timelines present cases via written documentation and verbal discussions in a group setting.
- Ability to review plan documents and identify areas of discrepancies and work with appropriate departments to ensure discrepancies are addressed to avoid rework.
Required Qualifications
- Demonstrate ability to handle multiple assignments competently, accurately and efficiently.
- Experience in reading or researching benefit language and application.
- Ability to maintain accuracy and production standards
- Excellent written and oral communication skills
- Ability to facilitate meetings and work with internal and external customers
- Ability to make appropriate decisions based upon Meritain and Aetna policies/guidelines
- Strong analytical skills focusing on accuracy and attention to detail
- Meritain application systems experience (CSI, DG)
Preferred Qualifications
- Experience in research and analysis of claim processing
- Knowledge of Meritain products
Education
Associate degree or equivalent work experience.
Business Overview
At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.
We are committed to maintaining a diverse and inclusive workplace. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.
Aetna
Hartford, CT
Aetna Inc. operates as a health care benefits company in the United States. It operates through three segments: Health Care, Group Insurance, and Large Case Pensions. The Health Care segment offers medical, pharmacy benefit management service, dental, behavioral health, and vision plans on an insured and employer-funded basis. It also provides point-of-service, preferred provider organization, health maintenance organization, and indemnity benefit plans, as well as health savings accounts and consumer-directed health plans.
In addition, this segment offers Medicare and Medicaid products and services, as well as other medical products, such as medical management and data analytics services, medical stop loss insurance, workers’ compensation administrative services, and products that provide access to its provider networks in select geographies. The Group Insurance segment offers life insurance products, including group term life insurance, voluntary spouse and dependent term life insurance, group universal life insurance, and accidental death and dismemberment insurance; disability insurance products; and long-term care insurance products, which provide the benefits to cover the cost of care in private home settings, adult day care, assisted living, or nursing facilities.
The Large Case Pensions segment manages various retirement products comprising pension and annuity products primarily for tax-qualified pension plans. The company provides its products and services to employer groups, individuals, college students, part-time and hourly workers, health plans, health care providers, governmental units, government-sponsored plans, labor groups, and expatriates. Aetna Inc. was founded in 1853 and is based in Hartford, Connecticut. As of November 28, 2018, Aetna Inc. operates as a subsidiary of CVS Pharmacy, Inc.
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IndustryInsurance
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No. of Employees47,950
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Website
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Jobs Posted12677
